Analgesics
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
BUTRANS DIS
15MCG/HR
2
$0
EMBEDA CAP 1004MG
2
$0
QL (60)
EMBEDA CAP 200.8MG
2
$0
QL (60)
EMBEDA CAP 301.2MG
2
$0
QL (60)
EMBEDA CAP 502MG
2
$0
QL (60)
EMBEDA CAP 602.4MG
2
$0
QL (60)
EMBEDA CAP 803.2MG
2
$0
QL (60)
fentanyl dis 100mcg/h
1
$0
ST, QL (10)
fentanyl dis 12mcg/hr
1
$0
ST, QL (10)
fentanyl dis 25mcg/hr
1
$0
ST, QL (10)
FENTANYL DIS
37.5MCG
2
$0
fentanyl dis 50mcg/hr
1
$0
FENTANYL DIS
62.5MCG
2
$0
fentanyl dis 75mcg/hr
1
$0
FENTANYL DIS
87.5MCG
2
$0
lorcet plus tab 7.5-325 1
$0
METHADONE INJ
10MG/ML
$0
2
ST, QL (10)
ST, QL (10)
QL (370)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
1
Name of Drug
Tier level
What the drug will
cost you
methadone sol
10mg/5ml
1
$0
methadone sol
5mg/5ml
1
$0
methadone tab 10mg
1
$0
methadone tab 5mg
1
$0
morphine sul cap
100mg er
1
$0
morphine sul cap
10mg er
1
$0
morphine sul cap
120mg er
1
$0
morphine sul cap
20mg er
1
$0
morphine sul cap
30mg er
1
$0
morphine sul cap
30mg er
1
$0
morphine sul cap
45mg er
1
$0
morphine sul cap
50mg er
1
$0
morphine sul cap
60mg er
1
$0
morphine sul cap
60mg er
1
$0
morphine sul cap
75mg er
1
$0
morphine sul cap
80mg er
1
$0
morphine sul cap
90mg er
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
2
Name of Drug
Tier level
What the drug will
cost you
morphine sul tab
100mg er
1
$0
morphine sul tab
15mg er
1
$0
morphine sul tab
30mg er
1
$0
morphine sul tab
60mg er
1
$0
NUCYNTA ER TAB
100MG
2
$0
NUCYNTA ER TAB
150MG
2
$0
NUCYNTA ER TAB
200MG
2
$0
NUCYNTA ER TAB
250MG
2
$0
NUCYNTA ER TAB
50MG
2
$0
OPANA ER TAB
10MG
2
$0
OPANA ER TAB
15MG
2
$0
OPANA ER TAB
20MG
2
$0
OPANA ER TAB
30MG
2
$0
OPANA ER TAB
40MG
2
$0
OPANA ER TAB 5MG
2
$0
OPANA ER TAB
7.5MG
2
$0
Necessary actions,
restrictions, or limits
on use
oxymorphone tab
10mg er
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
3
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
oxymorphone tab
15mg er
1
$0
oxymorphone tab
20mg er
1
$0
oxymorphone tab
30mg er
1
$0
oxymorphone tab
40mg er
1
$0
oxymorphone tab
5mg er
1
$0
oxymorphone tab
7.5mg er
1
$0
ZOHYDRO ER CAP
10MG
2
$0
PA
ZOHYDRO ER CAP
15MG
2
$0
PA
ZOHYDRO ER CAP
20MG
2
$0
PA
ZOHYDRO ER CAP
30MG
2
$0
PA
ZOHYDRO ER CAP
40MG
2
$0
PA
ZOHYDRO ER CAP
50MG
2
$0
PA
apap/codeine sol 12012/5
1
$0
QL (5000)
apap/codeine tab
300-15mg
1
$0
QL (400)
apap/codeine tab
300-30mg
1
$0
QL (400)
apap/codeine tab
300-60mg
1
$0
QL (400)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
4
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ascomp/cod cap
30mg
1
$0
PA
but/apap/caf cap
codeine
1
$0
PA, QL (370)
duramorph inj
0.5mg/ml
1
$0
duramorph inj 1mg/ml
1
$0
endocet tab 10325mg
1
$0
QL (370)
endocet tab 5-325mg
1
$0
QL (370)
endocet tab 7.5-325
1
$0
QL (370)
FENTORA TAB
200MCG
2
$0
PA
FENTORA TAB
400MCG
2
$0
PA
FENTORA TAB
600MCG
2
$0
PA
FENTORA TAB
800MCG
2
$0
PA
hydroco/apap sol 7.5325
1
$0
QL (5500)
hydroco/apap tab 10325mg
1
$0
QL (370)
hydroco/apap tab 2.5325
1
$0
QL (370)
hydroco/apap tab 5325mg
1
$0
QL (370)
hydroco/apap tab 7.5325
1
$0
QL (370)
hydrocod/ibu tab 7.5200
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
5
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
hydromorphon inj
500/50ml
1
$0
hydromorphon liq
1mg/ml
1
$0
hydromorphon tab
2mg
1
$0
hydromorphon tab
4mg
1
$0
hydromorphon tab
8mg
1
$0
LAZANDA SPR
100MCG
2
$0
PA
LAZANDA SPR
400MCG
2
$0
PA
morphine sul sol
10mg/5ml
1
$0
morphine sul sol
20mg/5ml
1
$0
morphine sul sol
20mg/ml
1
$0
morphine sul tab
15mg
1
$0
morphine sul tab
30mg
1
$0
nalbuphine inj
10mg/ml
1
$0
nalbuphine inj
20mg/ml
1
$0
NUCYNTA TAB
100MG
2
$0
NUCYNTA TAB
50MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
6
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
NUCYNTA TAB
75MG
2
$0
oxycod/apap tab 10325mg
1
$0
QL (370)
oxycod/apap tab 2.5325
1
$0
QL (370)
oxycod/apap tab 5325mg
1
$0
QL (370)
oxycod/apap tab 7.5325
1
$0
QL (370)
oxycod/asa tab
1
$0
oxycod/ibu tab 5400mg
1
$0
oxycodone cap 5mg
1
$0
oxycodone tab 10mg
1
$0
oxycodone tab 15mg
1
$0
oxycodone tab 20mg
1
$0
oxycodone tab 30mg
1
$0
oxycodone tab 5mg
1
$0
oxymorphone tab hcl
10mg
1
$0
oxymorphone tab hcl
5mg
1
$0
pentaz/nalox tab 500.5mg
1
$0
PA
tramadl/apap tab
37.5-325
1
$0
QL (370)
tramadol hcl tab 50mg 1
$0
QL (240)
Anesthetics
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
7
Name of Drug
Tier level
What the drug will
cost you
lido/prilocn cre 2.52.5%
1
$0
lidocaine gel 2% jelly
1
$0
lidocaine inj 0.5%
1
$0
lidocaine inj 2%
1
$0
Necessary actions,
restrictions, or limits
on use
Anti-Addiction/Substance Abuse Treatment Agents
Name of Drug
Tier level
What the drug will
cost you
acampro cal tab
333mg
1
$0
disulfiram tab 250mg
1
$0
disulfiram tab 500mg
1
$0
naltrexone tab 50mg
1
$0
bupren/nalox sub 20.5mg
1
$0
bupren/nalox sub 82mg
1
$0
buprenorphin inj
0.3mg/ml
1
$0
buprenorphin sub
2mg
1
$0
buprenorphin sub
8mg
1
$0
NALOXONE INJ
1MG/ML
1
$0
SUBOXONE MIS 123MG
2
$0
SUBOXONE MIS 41MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
8
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ZUBSOLV SUB 1.40.36
2
$0
ZUBSOLV SUB 5.71.4
2
$0
ZUBSOLV SUB 8.62.1
2
$0
CHANTIX PAK 0.5&
1MG
2
$0
QL (53)
CHANTIX PAK 1MG
2
$0
QL (56/28)
CHANTIX TAB 0.5MG 2
$0
QL (11)
CHANTIX TAB 1MG
2
$0
QL (180/90)
NICOTROL INH
2
$0
Anti-Addiction/Substance Abuse Treatment Agents (Nerve Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
nicorelief gum 2mg
orig
3
$0
nicorelief gum 4mg
orig
3
$0
NICORETTE
4MG ORIG
3
$0
nicotine td dis
14mg/24h
3
$0
nicotine td dis
21mg/24h
3
$0
nicotine td dis
7mg/24hr
3
$0
Necessary actions,
restrictions, or limits
on use
LOZ
Anti-Inflammatory Agents
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
9
Name of Drug
Tier level
What the drug will
cost you
celecoxib cap 100mg
2
$0
celecoxib cap 200mg
2
$0
celecoxib cap 400mg
2
$0
celecoxib cap 50mg
2
$0
diclofen pot tab 50mg
1
$0
diclofenac tab 100mg
er
1
$0
diclofenac tab 25mg
dr
1
$0
diclofenac tab 50mg
dr
1
$0
diclofenac tab 75mg
dr
1
$0
diflunisal tab 500mg
1
$0
etodolac cap 200mg
1
$0
etodolac cap 300mg
1
$0
etodolac er tab
400mg
1
$0
etodolac er tab
500mg
1
$0
etodolac er tab
600mg
1
$0
etodolac tab 400mg
1
$0
etodolac tab 500mg
1
$0
fenoprofen tab 600mg
1
$0
flurbiprofen tab
100mg
1
$0
flurbiprofen tab 50mg
1
$0
ibuprofen sus 100/5ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
10
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ibuprofen tab 400mg
1
$0
ibuprofen tab 600mg
1
$0
ibuprofen tab 800mg
1
$0
indomethacin cap
25mg
1
$0
PA
indomethacin cap
50mg
1
$0
PA
indomethacin cap
75mg er
1
$0
PA
ketoprofen cap
200mg er
1
$0
ketoprofen cap 50mg
1
$0
ketoprofen cap 75mg
1
$0
ketorolac inj 15mg/ml
1
$0
PA
ketorolac inj 30mg/ml
1
$0
PA
ketorolac tab 10mg
1
$0
PA
meclofen sod cap
100mg
1
$0
meclofen sod cap
50mg
1
$0
meloxicam sus
7.5/5ml
1
$0
meloxicam tab 15mg
1
$0
meloxicam tab 7.5mg
1
$0
nabumetone tab
500mg
1
$0
nabumetone tab
750mg
1
$0
naproxen dr tab
375mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
11
Name of Drug
Tier level
What the drug will
cost you
naproxen dr tab
500mg
1
$0
naproxen sod tab
275mg
1
$0
naproxen sod tab
550mg
1
$0
naproxen sus 125/5ml
1
$0
naproxen tab 250mg
1
$0
naproxen tab 375mg
1
$0
naproxen tab 500mg
1
$0
oxaprozin tab 600mg
1
$0
piroxicam cap 10mg
1
$0
piroxicam cap 20mg
1
$0
sulindac tab 150mg
1
$0
sulindac tab 200mg
1
$0
tolmetin sod cap
400mg
1
$0
tolmetin sod tab
600mg
1
$0
Necessary actions,
restrictions, or limits
on use
Anti-Inflammatory Agents (Pain, Inflammation, Muscle, Joint Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
acephen
120mg
sup
3
$0
acephen
325mg
sup
3
$0
acephen
650mg
sup
3
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
12
Name of Drug
Tier level
What the drug will
cost you
acetamin
160/5ml
3
$0
3
$0
arthrts pain tab
650mg
3
$0
aspir-81
ec
3
$0
apap
sol
tab 500mg
tab 81mg
aspirin
sup 300mg
3
$0
aspirin
sup 600mg
3
$0
aspirin
tab 325mg
3
$0
chw 81mg
3
$0
gnp aspirin tab
325mg ec
3
$0
hm ibuprofen tab
200mg
3
$0
ibuprofen
200mg
3
$0
mapap child tab
80mg rt
3
$0
pain & fever chw
80mg
3
$0
pain & fever sus
160/5ml
3
$0
pain relief dro
80/0.8ml
3
$0
pain relief sus
160/5ml
3
$0
tactinal
3
$0
3
$0
child asa
Necessary actions,
restrictions, or limits
on use
cap
tab 325mg
tri-buff asa tab 325mg
Antibacterials
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
13
Name of Drug
Tier level
What the drug will
cost you
gentam/nacl inj
0.9mg/ml
1
$0
gentam/nacl inj
1.4mg/ml
1
$0
gentam/nacl inj
100mg
1
$0
gentam/nacl inj 60mg
1
$0
gentam/nacl inj 80mg
1
$0
gentamicin inj
10mg/ml
1
$0
gentamicin inj
40mg/ml
1
$0
neomycin tab 500mg
1
$0
paromomycin cap
250mg
1
$0
streptomycin inj 1gm
1
$0
tobramycin inj
10mg/ml
1
$0
tobramycin inj
80mg/2ml
1
$0
tobramycin neb
300/5ml
1
$0
baciim inj 50000unt
1
$0
chloramphen inj 1gm
1
$0
clindamycin cap
150mg
1
$0
clindamycin cap
300mg
1
$0
clindamycin cap 75mg 1
$0
clindamycin inj
150mg/ml
$0
1
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
14
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
clindamycin inj 300mg
1
$0
clindamycin inj 600mg
1
$0
clindamycin inj 900mg
1
$0
clindamycin sol
75mg/5ml
1
$0
colistimeth inj 150mg
1
$0
CUBICIN SOL
500MG
2
$0
LINCOCIN INJ
300MG/ML
2
$0
linezolid inj 2mg/ml
1
$0
metron/nacl inj 500mg
1
$0
metronidazol cap
375mg
1
$0
metronidazol tab
250mg
1
$0
metronidazol tab
500mg
1
$0
nitrofur mac cap
50mg
1
$0
PA
nitrofurantn cap
100mg
1
$0
PA
SYNERCID INJ
500MG
2
$0
trimethoprim tab
100mg
1
$0
TYGACIL INJ 50MG
2
$0
vancomycin cap
125mg
1
$0
vancomycin cap
250mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
15
Name of Drug
Tier level
What the drug will
cost you
vancomycin inj
1000mg
1
$0
vancomycin inj 10gm
1
$0
vancomycin inj 500mg 1
$0
XIFAXAN TAB
550MG
2
$0
ZYVOX SUS
100MG/5M
2
$0
ZYVOX TAB 600MG
2
$0
cefaclor cap 250mg
1
$0
cefaclor cap 500mg
1
$0
cefaclor er tab 500mg
1
$0
cefazolin inj 10gm
1
$0
cefazolin inj 1gm
1
$0
cefazolin inj 1gm/50ml 1
$0
cefazolin inj 500mg
1
$0
cefdinir cap 300mg
1
$0
cefdinir sus 125/5ml
1
$0
cefdinir sus 250/5ml
1
$0
cefepime inj 1gm
1
$0
cefepime inj 2gm
1
$0
cefoxitin inj 10gm
1
$0
cefoxitin inj 1gm
1
$0
cefoxitin inj 2gm
1
$0
cefpodo prox sus
100/5ml
1
$0
Necessary actions,
restrictions, or limits
on use
cefpodo prox sus
50mg/5ml
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
16
Name of Drug
Tier level
What the drug will
cost you
cefpodoxime tab
100mg
1
$0
cefpodoxime tab
200mg
1
$0
cefprozil sus 125/5ml
1
$0
cefprozil sus 250/5ml
1
$0
cefprozil tab 250mg
1
$0
cefprozil tab 500mg
1
$0
ceftriaxone inj 10gm
1
$0
ceftriaxone inj 1gm
1
$0
ceftriaxone inj 250mg
1
$0
ceftriaxone inj 2gm
1
$0
ceftriaxone inj 500mg
1
$0
cefuroxime inj 1.5gm
1
$0
cefuroxime inj 7.5gm
1
$0
cefuroxime inj 750mg
1
$0
cefuroxime tab 250mg 1
$0
cephalexin cap
250mg
1
$0
cephalexin cap
500mg
1
$0
cephalexin sus
125/5ml
1
$0
cephalexin sus
250/5ml
1
$0
cephalexin tab 250mg
1
$0
cephalexin tab 500mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
17
Name of Drug
Tier level
What the drug will
cost you
SUPRAX CAP
400MG
2
$0
SUPRAX SUS
200/5ML
2
$0
TEFLARO INJ
400MG
2
$0
TEFLARO INJ
600MG
2
$0
AZACTAM/DEX INJ
1GM
2
$0
AZACTAM/DEX INJ
2GM
2
$0
aztreonam inj 1gm
1
$0
CAYSTON INH 75MG
2
$0
imipenem/cil inj
250mg
1
$0
imipenem/cil inj
500mg
1
$0
INVANZ INJ 1GM
2
$0
meropenem inj
500mg
1
$0
amox/k clav chw
200mg
1
$0
amox/k clav chw
400mg
1
$0
amox/k clav sus
200/5ml
1
$0
amox/k clav sus
400/5ml
1
$0
amox/k clav sus
600/5ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
18
Name of Drug
Tier level
What the drug will
cost you
amox/k clav tab
250mg
1
$0
amox/k clav tab
500mg
1
$0
amox/k clav tab
875mg
1
$0
amoxicillin cap 250mg
1
$0
amoxicillin cap 500mg
1
$0
amoxicillin chw
125mg
1
$0
amoxicillin chw
250mg
1
$0
amoxicillin sus
125/5ml
1
$0
amoxicillin sus
200/5ml
1
$0
amoxicillin sus
250/5ml
1
$0
amoxicillin sus
400/5ml
1
$0
amoxicillin tab 500mg
1
$0
amoxicillin tab 875mg
1
$0
amp-sulbacta inj
1.5gm
1
$0
amp-sulbacta inj
15gm
1
$0
ampicillin cap 250mg
1
$0
ampicillin cap 500mg
1
$0
ampicillin inj 10gm
1
$0
ampicillin inj 125mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
19
Name of Drug
Tier level
What the drug will
cost you
ampicillin inj 1gm
1
$0
ampicillin sus 125/5ml
1
$0
ampicillin sus 250/5ml
1
$0
BICILLIN L-A INJ
600000
2
$0
dicloxacill cap 250mg
1
$0
dicloxacill cap 500mg
1
$0
nafcillin inj 10gm
1
$0
nafcillin inj 1gm
1
$0
pen g sod inj 5000000
1
$0
penicill gk/ inj dex
2mu
1
$0
penicill gk/ inj dex
3mu
1
$0
penicilln gk inj 5mu
1
$0
penicilln vk sol
125/5ml
1
$0
penicilln vk sol
250/5ml
1
$0
penicilln vk tab 250mg 1
$0
penicilln vk tab 500mg 1
$0
piper/tazoba inj 30.375g
1
$0
piper/tazoba inj 40.5gm
1
$0
azithromycin inj
500mg
1
$0
azithromycin pow
1gm pak
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
20
Name of Drug
Tier level
What the drug will
cost you
azithromycin sus
100/5ml
1
$0
azithromycin sus
200/5ml
1
$0
azithromycin tab
250mg
1
$0
azithromycin tab
500mg
1
$0
azithromycin tab
600mg
1
$0
clarithromyc tab
250mg
1
$0
clarithromyc tab
500mg
1
$0
DIFICID TAB 200MG
2
$0
erythrocin inj 500mg
1
$0
erythrocin tab 250mg
1
$0
erythrom eth tab
400mg
1
$0
KETEK TAB 300MG
2
$0
KETEK TAB 400MG
2
$0
ciprofloxacn inj
200mg
1
$0
ciprofloxacn inj
400mg
1
$0
ciprofloxacn sus
250mg/5
1
$0
ciprofloxacn sus
500mg/5
1
$0
ciprofloxacn tab
1000mg
1
$0
Necessary actions,
restrictions, or limits
on use
ST
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
21
Name of Drug
Tier level
What the drug will
cost you
ciprofloxacn tab
100mg
1
$0
ciprofloxacn tab
250mg
1
$0
ciprofloxacn tab
500mg
1
$0
ciprofloxacn tab
500mg er
1
$0
ciprofloxacn tab
750mg
1
$0
levoflox/d5w inj
500/100m
1
$0
levofloxacin inj
25mg/ml
1
$0
levofloxacin sol
25mg/ml
1
$0
levofloxacin tab
250mg
1
$0
levofloxacin tab
500mg
1
$0
levofloxacin tab
750mg
1
$0
ofloxacin tab 300mg
1
$0
ofloxacin tab 400mg
1
$0
smz-tmp inj 400-80/5
1
$0
smz-tmp sus 200-40/5 1
$0
smz-tmp tab 40080mg
1
$0
smz/tmp ds tab 800160
1
$0
Necessary actions,
restrictions, or limits
on use
sulfadiazine tab
500mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
22
Name of Drug
Tier level
What the drug will
cost you
doxy 100 inj 100mg
2
$0
doxycyc mono tab
50mg
1
$0
doxycyc mono tab
75mg
1
$0
doxycycl hyc cap
100mg
1
$0
doxycycl hyc cap
50mg
1
$0
doxycycl hyc inj
100mg
1
$0
doxycycl hyc tab
100mg
1
$0
doxycycline sus
25mg/5ml
1
$0
doxycycline tab 20mg
1
$0
minocycline cap
100mg
1
$0
minocycline cap 50mg 1
$0
minocycline cap 75mg 1
$0
minocycline tab
100mg
1
$0
minocycline tab 50mg
1
$0
minocycline tab 75mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
LEVETIRACETA INJ
10MG/ML
2
$0
Necessary actions,
restrictions, or limits
on use
Anticonvulsants
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
23
Name of Drug
Tier level
What the drug will
cost you
LEVETIRACETA INJ
15MG/ML
2
$0
LEVETIRACETA INJ
5MG/ML
2
$0
levetiraceta sol
100mg/ml
1
$0
levetiraceta tab
1000mg
1
$0
levetiraceta tab
250mg
1
$0
levetiraceta tab
500mg
1
$0
levetiraceta tab
500mg er
1
$0
levetiraceta tab
750mg
1
$0
levetiraceta tab
750mg er
1
$0
levetiracetm inj
500/5ml
1
$0
POTIGA TAB 200MG
2
$0
POTIGA TAB 300MG
2
$0
POTIGA TAB 400MG
2
$0
POTIGA TAB 50MG
2
$0
phenobarb elx
20mg/5ml
1
$0
phenobarb tab 100mg
1
$0
phenobarb tab 15mg
1
$0
phenobarb tab
16.2mg
1
$0
phenobarb tab 30mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
24
Name of Drug
Tier level
What the drug will
cost you
phenobarb tab
32.4mg
1
$0
phenobarb tab 60mg
1
$0
phenobarb tab
64.8mg
1
$0
phenobarb tab
97.2mg
1
$0
clonazep odt tab
0.125mg
1
$0
clonazep odt tab
0.25mg
1
$0
clonazep odt tab
0.5mg
1
$0
clonazep odt tab 1mg
1
$0
clonazep odt tab 2mg
1
$0
clonazepam tab
0.5mg
1
$0
clonazepam tab 1mg
1
$0
clonazepam tab 2mg
1
$0
diazepam gel 10mg
1
$0
diazepam gel 2.5mg
1
$0
diazepam gel 20mg
1
$0
ONFI SUS 2.5MG/ML
2
$0
ONFI TAB 10MG
2
$0
ONFI TAB 20MG
2
$0
CELONTIN CAP
300MG
2
$0
ethosuximide cap
250mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
25
Name of Drug
Tier level
What the drug will
cost you
ethosuximide sol
250/5ml
1
$0
LYRICA CAP 200MG
2
$0
LYRICA CAP 225MG
2
$0
LYRICA CAP 25MG
2
$0
LYRICA CAP 300MG
2
$0
LYRICA CAP 50MG
2
$0
LYRICA CAP 75MG
2
$0
LYRICA SOL
20MG/ML
2
$0
zonisamide cap
100mg
1
$0
zonisamide cap 25mg
1
$0
zonisamide cap 50mg
1
$0
divalproex tab 250mg
dr
1
$0
divalproex tab 250mg
er
1
$0
divalproex tab 500mg
dr
1
$0
divalproex tab 500mg
er
1
$0
FYCOMPA TAB
10MG
2
$0
FYCOMPA TAB
12MG
2
$0
FYCOMPA TAB 2MG
2
$0
FYCOMPA TAB 4MG
2
$0
FYCOMPA TAB 6MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
26
Name of Drug
Tier level
What the drug will
cost you
FYCOMPA TAB 8MG
2
$0
gabapentin cap
100mg
1
$0
gabapentin cap
300mg
1
$0
gabapentin cap
400mg
1
$0
gabapentin sol
250/5ml
1
$0
gabapentin tab
600mg
1
$0
gabapentin tab
800mg
1
$0
GABITRIL TAB 12MG
2
$0
GABITRIL TAB 16MG
2
$0
primidone tab 250mg
1
$0
primidone tab 50mg
1
$0
SABRIL POW 500MG
2
$0
SABRIL TAB 500MG
2
$0
tiagabine tab 2mg
1
$0
tiagabine tab 4mg
1
$0
valproate inj 500/5ml
1
$0
valproic acd cap
250mg
1
$0
valproic acd syp
250/5ml
1
$0
felbamate sus
600/5ml
1
$0
felbamate tab 400mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
27
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
felbamate tab 600mg
1
$0
LAMICTAL KIT
START 35
2
$0
PA
LAMICTAL KIT
START 49
2
$0
PA
LAMICTAL KIT
START 98
2
$0
PA
LAMICTAL XR KIT
2
$0
PA
LAMICTAL XR KIT
2
$0
PA
LAMICTAL XR KIT
2
$0
PA
lamotrigine chw 25mg
1
$0
lamotrigine chw 5mg
1
$0
lamotrigine tab 100mg 1
$0
lamotrigine tab 100mg
er
1
$0
lamotrigine tab 150mg 1
$0
lamotrigine tab 200mg 1
$0
lamotrigine tab 200mg
er
1
$0
lamotrigine tab 250mg
er
1
$0
lamotrigine tab 25mg
1
$0
lamotrigine tab 25mg
er
1
$0
lamotrigine tab 300mg
er
1
$0
lamotrigine tab 50mg
er
1
$0
lamotrigine tab odt
25mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
28
Name of Drug
Tier level
What the drug will
cost you
lamotrigine tab odt
50mg
1
$0
lamotrigine tab
odt/100
1
$0
lamotrigine tab
odt/200
1
$0
QUDEXY XR CAP
100/24HR
2
$0
QUDEXY XR CAP
150/24HR
2
$0
QUDEXY XR CAP
200/24HR
2
$0
QUDEXY XR CAP
25/24HR
2
$0
QUDEXY XR CAP
50/24HR
2
$0
topiramate cap 15mg
1
$0
topiramate cap 25mg
1
$0
TOPIRAMATE CAP
ER 100MG
2
$0
TOPIRAMATE CAP
ER 150MG
2
$0
TOPIRAMATE CAP
ER 200MG
2
$0
TOPIRAMATE CAP
ER 25MG
2
$0
TOPIRAMATE CAP
ER 50MG
2
$0
topiramate tab 200mg
1
$0
topiramate tab 25mg
1
$0
topiramate tab 50mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
29
Name of Drug
Tier level
What the drug will
cost you
TROKENDI XR CAP
100MG
2
$0
TROKENDI XR CAP
200MG
2
$0
TROKENDI XR CAP
25MG
2
$0
TROKENDI XR CAP
50MG
2
$0
APTIOM TAB 200MG
2
$0
APTIOM TAB 400MG
2
$0
APTIOM TAB 600MG
2
$0
APTIOM TAB 800MG
2
$0
BANZEL SUS
40MG/ML
2
$0
BANZEL TAB 200MG
2
$0
BANZEL TAB 400MG
2
$0
carbamazepin cap
200mg er
1
$0
carbamazepin cap
300mg er
1
$0
carbamazepin sus
100/5ml
1
$0
carbamazepin tab
200mg
1
$0
carbamazepin tab
200mg er
1
$0
carbamazepin tab
400mg er
1
$0
CEREBYX INJ
500/10ML
2
$0
DILANTIN CAP 30MG 2
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
30
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
epitol tab 200mg
1
$0
EQUETRO CAP
100MG
2
$0
PA
EQUETRO CAP
200MG
2
$0
PA
EQUETRO CAP
300MG
2
$0
PA
fosphenytoin inj
100/2ml
1
$0
oxcarbazepin sus
300mg/5m
1
$0
oxcarbazepin tab
150mg
1
$0
oxcarbazepin tab
300mg
1
$0
oxcarbazepin tab
600mg
1
$0
OXTELLAR XR TAB
150MG
2
$0
OXTELLAR XR TAB
300MG
2
$0
OXTELLAR XR TAB
600MG
2
$0
PEGANONE TAB
250MG
2
$0
phenytoin chw 50mg
1
$0
phenytoin ex cap
100mg
1
$0
phenytoin ex cap
200mg
1
$0
phenytoin ex cap
300mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
31
Name of Drug
Tier level
What the drug will
cost you
phenytoin inj 50mg/ml
1
$0
phenytoin sus
125/5ml
1
$0
TEGRETOL-XR TAB
100MG
2
$0
VIMPAT INJ
200MG/20
2
$0
VIMPAT SOL
10MG/ML
2
$0
VIMPAT TAB 100MG
2
$0
VIMPAT TAB 150MG
2
$0
VIMPAT TAB 200MG
2
$0
VIMPAT TAB 50MG
2
$0
Name of Drug
Tier level
What the drug will
cost you
ergoloid mes tab 1mg
oral
1
$0
donepezil tab 10mg
1
$0
donepezil tab 10mg
odt
1
$0
donepezil tab 5mg
1
$0
donepezil tab 5mg odt
1
$0
donepezil tab hcl
23mg
1
$0
EXELON DIS 13.3/24
2
$0
EXELON DIS
4.6MG/24
2
$0
Necessary actions,
restrictions, or limits
on use
Antidementia Agents
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
32
Name of Drug
Tier level
What the drug will
cost you
EXELON DIS
9.5MG/24
2
$0
galantamine cap
16mg er
1
$0
galantamine cap
24mg er
1
$0
galantamine cap 8mg
er
1
$0
GALANTAMINE SOL
4MG/ML
1
$0
galantamine tab 12mg 1
$0
galantamine tab 4mg
1
$0
galantamine tab 8mg
1
$0
rivastigmine cap
1.5mg
1
$0
rivastigmine cap 3mg
1
$0
rivastigmine cap
4.5mg
1
$0
rivastigmine cap 6mg
1
$0
NAMENDA SOL
10MG/5ML
2
$0
NAMENDA XR CAP
14MG
2
$0
NAMENDA XR CAP
21MG
2
$0
NAMENDA XR CAP
28MG
2
$0
NAMENDA XR CAP
7MG
2
$0
NAMENDA XR CAP
TITRATIO
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
33
Antidepressants
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
APLENZIN TAB
174MG
2
$0
APLENZIN TAB
348MG
2
$0
APLENZIN TAB
522MG
2
$0
PA
BRINTELLIX TAB
10MG
2
$0
ST
BRINTELLIX TAB
20MG
2
$0
ST
BRINTELLIX TAB
5MG
2
$0
ST
buproban tab 150mg
1
$0
bupropion tab 100mg
1
$0
bupropion tab 100mg
sr
1
$0
bupropion tab 150mg
sr
1
$0
bupropion tab 200mg
sr
1
$0
bupropion tab 75mg
1
$0
bupropn hcl tab
150mg xl
1
$0
bupropn hcl tab
300mg xl
1
$0
FORFIVO XL TAB
450MG
2
$0
maprotiline tab 25mg
1
$0
maprotiline tab 50mg
1
$0
maprotiline tab 75mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
34
Name of Drug
Tier level
What the drug will
cost you
mirtazapine tab 15mg
1
$0
mirtazapine tab 15mg
odt
1
$0
mirtazapine tab 30mg
1
$0
mirtazapine tab 30mg
odt
1
$0
mirtazapine tab 45mg
1
$0
mirtazapine tab 45mg
odt
1
$0
mirtazapine tab 7.5mg 1
$0
nefazodone tab
100mg
1
$0
nefazodone tab
150mg
1
$0
nefazodone tab
200mg
1
$0
nefazodone tab
250mg
1
$0
nefazodone tab 50mg
1
$0
trazodone tab 100mg
1
$0
trazodone tab 150mg
1
$0
trazodone tab 300mg
1
$0
trazodone tab 50mg
1
$0
VIIBRYD KIT
2
$0
VIIBRYD TAB 10MG
2
$0
VIIBRYD TAB 20MG
2
$0
VIIBRYD TAB 40MG
2
$0
EMSAM DIS
12MG/24H
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
35
Name of Drug
Tier level
What the drug will
cost you
EMSAM DIS
6MG/24HR
2
$0
EMSAM DIS
9MG/24HR
2
$0
MARPLAN TAB
10MG
2
$0
phenelzine tab 15mg
1
$0
tranylcyprom tab
10mg
1
$0
BRISDELLE CAP
7.5MG
2
$0
citalopram sol
10mg/5ml
1
$0
citalopram tab 10mg
1
$0
citalopram tab 20mg
1
$0
citalopram tab 40mg
1
$0
DESVENLAFAX TAB
100MG ER
2
$0
DESVENLAFAX TAB
50MG ER
2
$0
duloxetine cap 20mg
1
$0
duloxetine cap 30mg
1
$0
duloxetine cap 60mg
1
$0
escitalopram sol
5mg/5ml
1
$0
escitalopram tab
10mg
1
$0
escitalopram tab
20mg
1
$0
escitalopram tab 5mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
36
Name of Drug
Tier level
What the drug will
cost you
FETZIMA CAP
120MG
2
$0
FETZIMA CAP 20MG
2
$0
FETZIMA CAP 40MG
2
$0
FETZIMA CAP 80MG
2
$0
fluoxetine cap 10mg
1
$0
fluoxetine cap 20mg
1
$0
fluoxetine cap 40mg
1
$0
fluoxetine cap 90mg
dr
1
$0
fluoxetine sol
20mg/5ml
1
$0
fluoxetine tab 10mg
1
$0
fluoxetine tab 20mg
1
$0
FLUOXETINE TAB
60MG
2
$0
fluvoxamine cap
100mg er
1
$0
fluvoxamine cap
150mg er
1
$0
fluvoxamine tab
100mg
1
$0
fluvoxamine tab 25mg
1
$0
fluvoxamine tab 50mg
1
$0
KHEDEZLA TAB
100MG ER
2
$0
KHEDEZLA TAB
50MG ER
2
$0
olanza/fluox cap 1225mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
37
Name of Drug
Tier level
What the drug will
cost you
olanza/fluox cap 1250mg
1
$0
olanza/fluox cap 325mg
1
$0
olanza/fluox cap 625mg
1
$0
olanza/fluox cap 650mg
1
$0
paroxetin er tab
12.5mg
1
$0
paroxetin er tab
37.5mg
1
$0
paroxetine tab 10mg
1
$0
paroxetine tab 20mg
1
$0
paroxetine tab 25mg
er
1
$0
paroxetine tab 30mg
1
$0
paroxetine tab 40mg
1
$0
PAXIL SUS
10MG/5ML
2
$0
PEXEVA TAB 10MG
2
$0
PEXEVA TAB 20MG
2
$0
PEXEVA TAB 30MG
2
$0
PEXEVA TAB 40MG
2
$0
PRISTIQ TAB 100MG
2
$0
PRISTIQ TAB 25MG
2
$0
PRISTIQ TAB 50MG
2
$0
sertraline con
20mg/ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
38
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
sertraline tab 100mg
1
$0
sertraline tab 25mg
1
$0
sertraline tab 50mg
1
$0
venlafaxine cap
150mg er
1
$0
venlafaxine cap 37.5
er
1
$0
venlafaxine cap 75mg
er
1
$0
venlafaxine tab
100mg
1
$0
venlafaxine tab
150mg er
1
$0
venlafaxine tab
225mg er
1
$0
venlafaxine tab 25mg
1
$0
venlafaxine tab 37.5
er
1
$0
venlafaxine tab
37.5mg
1
$0
venlafaxine tab 50mg
1
$0
venlafaxine tab 75mg
1
$0
venlafaxine tab 75mg
er
1
$0
amitriptylin tab 100mg
1
$0
PA
amitriptylin tab 10mg
1
$0
PA
amitriptylin tab 150mg
1
$0
PA
amitriptylin tab 25mg
1
$0
PA
amitriptylin tab 50mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
39
Necessary actions,
restrictions, or limits
on use
PA
Name of Drug
Tier level
What the drug will
cost you
amitriptylin tab 75mg
1
$0
amoxapine tab 100mg 1
$0
amoxapine tab 150mg 1
$0
amoxapine tab 25mg
1
$0
amoxapine tab 50mg
1
$0
cdp/amitrip tab 1025mg
1
$0
PA
cdp/amitrip tab 512.5mg
1
$0
PA
clomipramine cap
25mg
1
$0
PA
clomipramine cap
50mg
1
$0
PA
clomipramine cap
75mg
1
$0
PA
desipramine tab
100mg
1
$0
desipramine tab 10mg 1
$0
desipramine tab
150mg
1
$0
desipramine tab 25mg 1
$0
desipramine tab 50mg 1
$0
desipramine tab 75mg 1
$0
doxepin hcl cap
100mg
1
$0
PA
doxepin hcl cap 10mg
1
$0
PA
doxepin hcl cap
150mg
1
$0
PA
doxepin hcl cap 25mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
40
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
doxepin hcl cap 50mg
1
$0
PA
doxepin hcl cap 75mg
1
$0
PA
doxepin hcl con
10mg/ml
1
$0
PA
imipram hcl tab 10mg
1
$0
PA
imipram hcl tab 25mg
1
$0
PA
imipram hcl tab 50mg
1
$0
PA
imipram pam cap
100mg
1
$0
PA
imipram pam cap
125mg
1
$0
PA
imipram pam cap
150mg
1
$0
PA
imipram pam cap
75mg
1
$0
PA
nortriptylin cap 10mg
1
$0
nortriptylin cap 25mg
1
$0
nortriptylin cap 50mg
1
$0
nortriptylin cap 75mg
1
$0
NORTRIPTYLIN SOL
10MG/5ML
2
$0
protriptylin tab 10mg
1
$0
protriptylin tab 5mg
1
$0
SURMONTIL CAP
100MG
2
$0
SURMONTIL CAP
25MG
2
$0
SURMONTIL CAP
50MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
41
Antiemetics
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
meclizine tab 12.5mg
1
$0
meclizine tab 25mg
1
$0
metoclopram tab
10mg
1
$0
TRANSDERM-SC
DIS 1.5MG
2
$0
dronabinol cap 10mg
1
$0
PA, QL (60)
dronabinol cap 2.5mg
1
$0
PA, QL (60)
dronabinol cap 5mg
1
$0
PA, QL (60)
EMEND CAP 125MG
2
$0
PA, QL (30)
EMEND CAP 40MG
2
$0
PA, QL (30)
EMEND CAP 80MG
2
$0
PA, QL (30)
EMEND PAK 80 &
125
2
$0
PA, QL (12)
granisetron inj
0.1mg/ml
1
$0
PA, QL (60)
granisetron inj 1mg/ml
1
$0
PA, QL (60)
granisetron tab 1mg
1
$0
PA, QL (60)
ondansetron inj
4mg/2ml
1
$0
PA, QL (160)
ondansetron inj
4mg/2ml
1
$0
ondansetron sol
4mg/5ml
1
$0
PA
ondansetron tab
24mg
1
$0
PA, QL (30)
ondansetron tab 4mg
1
$0
PA, QL (60)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
42
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ondansetron tab 4mg
odt
1
$0
PA, QL (60)
ondansetron tab 8mg
1
$0
PA, QL (60)
ondansetron tab 8mg
odt
1
$0
PA, QL (60)
SANCUSO DIS
3.1MG
2
$0
QL (4)
Antiemetics (Bowel, Instestine, And Stomach Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
all day allg sol
5mg/5ml
3
$0
aller-chlor syp
2mg/5ml
3
$0
driminate
3
$0
3
$0
Name of Drug
Tier level
What the drug will
cost you
ABELCET INJ
5MG/ML
2
$0
AMBISOME INJ
50MG
2
$0
amphotericin inj 50mg
1
$0
CANCIDAS INJ
50MG
2
$0
tab 50mg
gnp allergy tab
180mg
Necessary actions,
restrictions, or limits
on use
Antifungals
Necessary actions,
restrictions, or limits
on use
CANCIDAS INJ
2
$0
70MG
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
43
Name of Drug
Tier level
What the drug will
cost you
clotrimazole tro 10mg
1
$0
ERAXIS INJ 100MG
2
$0
fluconazole sus
10mg/ml
1
$0
fluconazole sus
40mg/ml
1
$0
fluconazole tab
100mg
1
$0
fluconazole tab
150mg
1
$0
fluconazole tab
200mg
1
$0
fluconazole tab 50mg
1
$0
fluconazole/ inj dex
400
1
$0
flucytosine cap
250mg
1
$0
flucytosine cap
500mg
1
$0
griseofulvin sus
125/5ml
1
$0
itraconazole cap
100mg
1
$0
ketoconazole tab
200mg
1
$0
MYCAMINE INJ
100MG
2
$0
MYCAMINE INJ
50MG
2
$0
NOXAFIL SUS
40MG/ML
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
44
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
NOXAFIL TAB
100MG
2
$0
nystatin tab 500000
1
$0
voriconazole inj
200mg
1
$0
voriconazole sus
40mg/ml
1
$0
voriconazole tab
200mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
allopurinol tab 100mg
1
$0
allopurinol tab 300mg
1
$0
COLCHICINE CAP
0.6MG
1
$0
COLCHICINE TAB
0.6MG
1
$0
probenecid tab
500mg
1
$0
ULORIC TAB 40MG
2
$0
ST
ULORIC TAB 80MG
2
$0
ST
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
divalproex cap 125mg
1
$0
divalproex tab 125mg
dr
1
$0
Antigout Agents
Necessary actions,
restrictions, or limits
on use
Antimigraine Agents
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
45
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
topiramate tab 100mg
1
$0
dihydroergot inj
1mg/ml
1
$0
ERGOMAR SUB
2MG
2
$0
RELPAX TAB 20MG
2
$0
QL (9)
RELPAX TAB 40MG
2
$0
QL (9)
sumatriptan inj
6mg/0.5
1
$0
QL (10)
sumatriptan inj
6mg/0.5
1
$0
QL (4.5)
sumatriptan tab
100mg
1
$0
QL (9)
sumatriptan tab 25mg
1
$0
QL (9)
sumatriptan tab 50mg
1
$0
QL (9)
Necessary actions,
restrictions, or limits
on use
Antimyasthenic Agents
Name of Drug
Tier level
What the drug will
cost you
GUANIDINE TAB
125MG
2
$0
MESTINON SYP
60MG/5ML
2
$0
pyridostigm tab 60mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
dapsone tab 100mg
1
$0
Antimycobacterials
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
46
Name of Drug
Tier level
What the drug will
cost you
dapsone tab 25mg
1
$0
pyrazinamide tab
500mg
1
$0
rifabutin cap 150mg
1
$0
CAPASTAT SUL INJ
1GM
2
$0
ethambutol tab
100mg
1
$0
ethambutol tab
400mg
1
$0
isoniazid inj 100mg/ml
1
$0
isoniazid syp
50mg/5ml
1
$0
isoniazid tab 100mg
1
$0
isoniazid tab 300mg
1
$0
PASER GRA 4GM
2
$0
PRIFTIN TAB 150MG
2
$0
rifampin cap 150mg
1
$0
rifampin cap 300mg
1
$0
rifampin inj 600 mg
1
$0
RIFATER TAB
2
$0
SIRTURO TAB
100MG
2
$0
TRECATOR TAB
250MG
2
$0
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
Antineoplastics
Name of Drug
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
47
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
CYCLOPHOSPH
CAP 25MG
2
$0
PA
CYCLOPHOSPH
CAP 50MG
2
$0
PA
GLEOSTINE CAP
100MG
2
$0
GLEOSTINE CAP
10MG
2
$0
GLEOSTINE CAP
40MG
2
$0
HEXALEN CAP
50MG
2
$0
LEUKERAN TAB
2MG
2
$0
lomustine cap 100mg
1
$0
lomustine cap 10mg
1
$0
lomustine cap 40mg
1
$0
AVASTIN INJ
2
$0
DEPEN TITRA TAB
250MG
2
$0
REVLIMID CAP
10MG
2
$0
LA
REVLIMID CAP
15MG
2
$0
LA
REVLIMID CAP
2.5MG
2
$0
REVLIMID CAP
20MG
2
$0
REVLIMID CAP
25MG
2
$0
LA
REVLIMID CAP 5MG
2
$0
LA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
48
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
SYPRINE CAP
250MG
2
$0
THALOMID CAP
100MG
2
$0
THALOMID CAP
150MG
2
$0
THALOMID CAP
200MG
2
$0
THALOMID CAP
50MG
2
$0
ALIMTA INJ 500MG
2
$0
azacitidine inj 100mg
1
$0
DACOGEN INJ 50MG
2
$0
decitabine inj 50mg
1
$0
fludarabine inj 50mg
1
$0
gemcitabine inj 1gm
1
$0
mercaptopur tab
50mg
1
$0
methotrexate inj 1gm
1
$0
PA
methotrexate inj
1gm/40ml
1
$0
PA
methotrexate tab
2.5mg
1
$0
PA
PRIMAQUINE TAB
26.3MG
2
$0
PURIXAN SUS
20MG/ML
2
$0
TABLOID TAB 40MG
2
$0
ABRAXANE INJ
100MG
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
49
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ACTIMMUNE INJ
2MU/0.5
2
$0
LA
adrucil inj 500/10ml
1
$0
PA
AFINITOR DIS TAB
2MG
2
$0
AFINITOR DIS TAB
3MG
2
$0
AFINITOR DIS TAB
5MG
2
$0
AFINITOR TAB 10MG 2
$0
AFINITOR TAB
2.5MG
2
$0
AFINITOR TAB 5MG
2
$0
AFINITOR TAB
7.5MG
2
$0
amifostine inj 500mg
1
$0
PA
ARRANON INJ
5MG/ML
2
$0
PA
ARZERRA CON
100/5ML
2
$0
PA
AZASAN TAB 100MG
2
$0
PA
AZASAN TAB 75 MG
2
$0
PA
BELEODAQ INJ
500MG
2
$0
bicalutamide tab
50mg
1
$0
BICNU INJ 100MG
2
$0
bleomycin inj 30unit
1
$0
BOSULIF TAB
100MG
2
$0
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
50
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
BOSULIF TAB
500MG
2
$0
PA
BUSULFEX INJ
6MG/ML
2
$0
PA
CAPRELSA TAB
100MG
2
$0
CAPRELSA TAB
300MG
2
$0
CARAC CRE 0.5%
2
$0
PA
carboplatin inj
150/15ml
1
$0
PA
cisplatin inj 100mg
1
$0
PA
cladribine inj 1mg/ml
1
$0
PA
CLOLAR INJ 1MG/ML 2
$0
PA
COMETRIQ KIT
100MG
2
$0
COMETRIQ KIT
140MG
2
$0
COMETRIQ KIT
60MG
2
$0
COSMEGEN INJ
0.5MG
2
$0
PA
cytarabine inj
100mg/ml
1
$0
PA
cytarabine inj
20mg/ml
1
$0
PA
dacarbazine inj
200mg
1
$0
PA
daunorubicin inj
5mg/ml
1
$0
PA
DAUNOXOME INJ
2MG/ML
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
51
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
DEPO-PROVERA INJ
400/ML
2
$0
PA
dexrazoxane inj
250mg
1
$0
PA
DOCEFREZ INJ
20MG
2
$0
PA
DOCETAXEL INJ
80MG/4ML
2
$0
DOCETAXEL INJ
80MG/8ML
2
$0
DOXIL INJ 2MG/ML
2
$0
PA
doxorubicin inj 50mg
1
$0
PA
ELIGARD INJ
22.5MG
2
$0
PA
ELIGARD INJ 30MG
2
$0
PA
ELIGARD INJ 45MG
2
$0
PA
ELIGARD INJ 7.5MG
2
$0
PA
ELITEK INJ 1.5MG
2
$0
PA
ELLENCE INJ
2MG/ML
2
$0
PA
EMCYT CAP 140MG
2
$0
epirubicin inj 50/25ml
1
$0
PA
ERBITUX INJ 100MG
2
$0
PA
ERIVEDGE CAP
150MG
2
$0
ERWINAZE INJ
10000UNT
2
$0
PA
ETOPOPHOS INJ
100MG
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
52
Necessary actions,
restrictions, or limits
on use
PA
Name of Drug
Tier level
What the drug will
cost you
etoposide inj
500/25ml
1
$0
FARESTON TAB
60MG
2
$0
FARYDAK CAP
10MG
2
$0
PA
FARYDAK CAP
15MG
2
$0
PA
FARYDAK CAP
20MG
2
$0
PA
FASLODEX INJ
250MG
2
$0
PA
FIRMAGON INJ
120MG
2
$0
PA
FIRMAGON INJ
80MG
2
$0
PA
fluorouracil inj
2.5g/50m
1
$0
PA
fluorouracil sol 2%
1
$0
fluorouracil sol 5%
1
$0
flutamide cap 125mg
1
$0
FOLOTYN INJ
40MG/2ML
2
$0
PA
FUSILEV INJ 50MG
2
$0
PA
GILOTRIF TAB 20MG
2
$0
PA
GILOTRIF TAB 30MG
2
$0
PA
GILOTRIF TAB 40MG
2
$0
PA
GLEEVEC TAB
100MG
2
$0
GLEEVEC TAB
400MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
53
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
HALAVEN INJ
1MG/2ML
2
$0
HERCEPTIN INJ
440MG
2
$0
hydroxyurea cap
500mg
1
$0
IBRANCE CAP
100MG
2
$0
PA
IBRANCE CAP
125MG
2
$0
PA
IBRANCE CAP 75MG
2
$0
PA
ICLUSIG TAB 15MG
2
$0
PA
ICLUSIG TAB 45MG
2
$0
PA
IDAMYCIN PFS INJ
20/20ML
2
$0
PA
idarubicin inj 10/10ml
1
$0
PA
IFEX INJ 1GM
2
$0
PA
ifosfamide inj 1gm
1
$0
PA
IMBRUVICA CAP
140MG
2
$0
PA
INLYTA TAB 1MG
2
$0
INLYTA TAB 5MG
2
$0
INTRON A INJ 18MU
2
$0
INTRON A INJ 50MU
2
$0
INTRON-A INJ 10MU
2
$0
INTRON-A INJ 18MU
2
$0
irinotecan inj 100/5ml
1
$0
ISTODAX INJ 10MG
2
$0
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
54
Necessary actions,
restrictions, or limits
on use
PA
Name of Drug
Tier level
What the drug will
cost you
IXEMPRA KIT INJ
45MG
2
$0
JAKAFI TAB 10MG
2
$0
JAKAFI TAB 15MG
2
$0
JAKAFI TAB 20MG
2
$0
JAKAFI TAB 25MG
2
$0
JAKAFI TAB 5MG
2
$0
JEVTANA INJ
60/1.5ML
2
$0
KADCYLA INJ
100MG
2
$0
KEPIVANCE INJ
6.25MG
2
$0
PA
KEYTRUDA SOL
50MG
2
$0
PA
LENVIMA CAP 10MG
2
$0
LENVIMA CAP 14MG
2
$0
LENVIMA CAP 20MG
2
$0
LENVIMA CAP 24MG
2
$0
leucovor ca inj 100mg
1
$0
PA
leucovor ca inj 350mg
1
$0
PA
leucovor ca tab 10mg
1
$0
leucovor ca tab 15mg
1
$0
leucovor ca tab 25mg
1
$0
leucovor ca tab 5mg
1
$0
leuprolide inj 1mg/0.2
1
$0
LEVOLEUCOVOR
INJ 50MG
2
$0
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
55
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
LUPRON DEPOT INJ
22.5MG
2
$0
LUPRON DEPOT INJ
3.75MG
2
$0
LUPRON DEPOT INJ
30MG
2
$0
LUPRON DEPOT INJ
45MG
2
$0
LUPRON DEPOT INJ
7.5MG
2
$0
LYNPARZA CAP
50MG
2
$0
LYSODREN TAB
500MG
2
$0
MATULANE CAP
50MG
2
$0
MEGACE ES SUS
625/5ML
2
$0
PA
megestrol ac sus
40mg/ml
1
$0
PA
megestrol ac tab
20mg
1
$0
PA
megestrol ac tab
40mg
1
$0
PA
MEKINIST TAB
0.5MG
2
$0
LA
MEKINIST TAB 2MG
2
$0
LA
melphalan inj 50mg
1
$0
PA
mesna inj 1gm
1
$0
PA
MESNEX TAB
400MG
2
$0
PA
mitomycin inj 20mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
56
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
mitoxantron inj
2mg/ml
1
$0
MUSTARGEN INJ
10MG
2
$0
PA
NEXAVAR TAB
200MG
2
$0
LA
NILANDRON TAB
150MG
2
$0
NIPENT INJ 10MG
2
$0
PA
ONCASPAR INJ
750/ML
2
$0
PA
OPDIVO INJ
40MG/4ML
2
$0
PA
oxaliplatin inj 100mg
1
$0
PA
paclitaxel inj 300/50ml
1
$0
PA
PERJETA INJ
420/14ML
2
$0
POMALYST CAP
1MG
2
$0
LA
POMALYST CAP
2MG
2
$0
LA
POMALYST CAP
3MG
2
$0
LA
POMALYST CAP
4MG
2
$0
LA
PROLEUKIN INJ
22MU
2
$0
PA
RHEUMATREX TAB
2.5MG
2
$0
PA
RITUXAN INJ 500MG
2
$0
SPRYCEL TAB
100MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
57
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
SPRYCEL TAB
140MG
2
$0
SPRYCEL TAB 20MG 2
$0
SPRYCEL TAB 50MG 2
$0
SPRYCEL TAB 70MG 2
$0
SPRYCEL TAB 80MG 2
$0
STIVARGA TAB
40MG
2
$0
SUTENT CAP
12.5MG
2
$0
SUTENT CAP 25MG
2
$0
SUTENT CAP
37.5MG
2
$0
SUTENT CAP 50MG
2
$0
SYLATRON KIT
296MCG
2
$0
SYLATRON KIT
444MCG
2
$0
SYLATRON KIT
888MCG
2
$0
SYNRIBO INJ 3.5MG
2
$0
TAFINLAR CAP
50MG
2
$0
LA
TAFINLAR CAP
75MG
2
$0
LA
tamoxifen tab 10mg
1
$0
tamoxifen tab 20mg
1
$0
TARCEVA TAB
100MG
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
58
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
TARCEVA TAB
150MG
2
$0
TARCEVA TAB
25MG
2
$0
TARGRETIN CAP
75MG
2
$0
TASIGNA CAP
150MG
2
$0
TASIGNA CAP
200MG
2
$0
TAXOTERE INJ
80MG/4ML
2
$0
PA
toposar inj 1gm/50ml
1
$0
PA
topotecan inj 4mg
1
$0
PA
TORISEL SOL
25MG/ML
2
$0
PA
TREANDA INJ
100MG
2
$0
PA
TREANDA INJ
45/0.5ML
2
$0
TRELSTAR DEP INJ
3.75MG
2
$0
PA
TRELSTAR LA INJ
11.25MG
2
$0
PA
TRELSTAR MIX INJ
22.5MG
2
$0
PA
tretinoin cap 10mg
1
$0
TRISENOX SOL
10MG/10M
2
$0
TYKERB TAB 250MG
2
$0
PA
UVADEX INJ
20MCG/ML
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
59
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
VECTIBIX INJ 100MG 2
$0
PA
VELCADE INJ 3.5MG
2
$0
vinblastine inj 1mg/ml
1
$0
PA
vincasar pfs inj
1mg/ml
1
$0
PA
vincristine inj 1mg/ml
1
$0
PA
vinorelbine inj
10mg/ml
1
$0
PA
VOTRIENT TAB
200MG
2
$0
XALKORI CAP
200MG
2
$0
PA
XALKORI CAP
250MG
2
$0
PA
XTANDI CAP 40MG
2
$0
PA
YERVOY INJ 50MG
2
$0
ZALTRAP INJ
100/4ML
2
$0
ZANOSAR INJ 1GM
2
$0
ZELBORAF TAB
240MG
2
$0
ZINECARD INJ
250MG
2
$0
ZOLINZA CAP
100MG
2
$0
ZYDELIG TAB
100MG
2
$0
ZYDELIG TAB
150MG
2
$0
ZYKADIA CAP
150MG
2
$0
Name of Drug
Tier level
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
60
Name of Drug
Tier level
What the drug will
cost you
ZYTIGA TAB 250MG
2
$0
anastrozole tab 1mg
1
$0
exemestane tab 25mg 1
$0
letrozole tab 2.5mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
ALBENZA TAB
200MG
2
$0
ivermectin tab 3mg
2
$0
ALINIA SUS 100/5ML
2
$0
ALINIA TAB 500MG
2
$0
atovaq/progu tab 250100
1
$0
atovaquone sus
750/5ml
1
$0
chloroquine tab
250mg
1
$0
chloroquine tab
500mg
1
$0
COARTEM TAB 20120MG
2
$0
DARAPRIM TAB
25MG
2
$0
hydroxychlor tab
200mg
1
$0
mefloquine tab 250mg 1
$0
NEBUPENT INH
300MG
$0
Necessary actions,
restrictions, or limits
on use
Antiparasitics
2
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
61
Name of Drug
Tier level
What the drug will
cost you
PENTAM 300 INJ
300MG
2
$0
quinine sulf cap
324mg
1
$0
Necessary actions,
restrictions, or limits
on use
Antiparkinson Agents
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
benztropine inj
1mg/ml
1
$0
benztropine tab
0.5mg
1
$0
PA
benztropine tab 1mg
1
$0
PA
benztropine tab 2mg
1
$0
PA
trihexyphen elx
0.4mg/ml
1
$0
PA
trihexyphen tab 2mg
1
$0
PA
trihexyphen tab 5mg
1
$0
PA
amantadine cap
100mg
1
$0
amantadine syp
50mg/5ml
1
$0
amantadine tab
100mg
1
$0
entacapone tab
200mg
1
$0
APOKYN INJ
10MG/ML
2
$0
bromocriptin cap 5mg
1
$0
bromocriptin tab
2.5mg
1
$0
LA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
62
Name of Drug
Tier level
What the drug will
cost you
NEUPRO DIS
1MG/24HR
2
$0
NEUPRO DIS
2MG/24HR
2
$0
NEUPRO DIS
3MG/24HR
2
$0
NEUPRO DIS
4MG/24HR
2
$0
NEUPRO DIS
6MG/24HR
2
$0
NEUPRO DIS
8MG/24HR
2
$0
pramipexole tab
0.125mg
1
$0
pramipexole tab
0.25mg
1
$0
pramipexole tab
0.5mg
1
$0
pramipexole tab
0.75mg
1
$0
pramipexole tab
1.5mg
1
$0
pramipexole tab 1mg
1
$0
ropinirole tab 0.25mg
1
$0
ropinirole tab 0.5mg
1
$0
ropinirole tab 1mg
1
$0
ropinirole tab 2mg
1
$0
ropinirole tab 3mg
1
$0
ropinirole tab 4mg
1
$0
ropinirole tab 5mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
63
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
carb/levo er tab 25100mg
1
$0
carb/levo er tab 50200mg
1
$0
carb/levo tab 10100mg
1
$0
carb/levo tab 10100mg
1
$0
carb/levo tab 25100mg
1
$0
carb/levo tab 25100mg
1
$0
carb/levo tab 25250mg
1
$0
carb/levo tab 25250mg
1
$0
AZILECT TAB 0.5MG
2
$0
AZILECT TAB 1MG
2
$0
selegiline cap 5mg
1
$0
selegiline tab 5mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
chlorpromaz inj
25mg/ml
1
$0
PA
chlorpromaz tab
100mg
1
$0
chlorpromaz tab
10mg
1
$0
Antipsychotics
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
64
Name of Drug
Tier level
What the drug will
cost you
chlorpromaz tab
200mg
1
$0
chlorpromaz tab
25mg
1
$0
chlorpromaz tab
50mg
1
$0
compro sup 25mg
1
$0
fluphenaz de inj
25mg/ml
1
$0
fluphenazine con
5mg/ml
1
$0
fluphenazine elx
2.5/5ml
1
$0
fluphenazine inj
2.5mg/ml
1
$0
fluphenazine tab
10mg
1
$0
fluphenazine tab 1mg
1
$0
fluphenazine tab
2.5mg
1
$0
fluphenazine tab 5mg
1
$0
haloper dec inj
100mg/ml
1
$0
haloper dec inj
50mg/ml
1
$0
haloper lac inj 5mg/ml
1
$0
haloperidol con
2mg/ml
1
$0
haloperidol tab 0.5mg
1
$0
haloperidol tab 10mg
1
$0
haloperidol tab 1mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
65
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
haloperidol tab 20mg
1
$0
haloperidol tab 2mg
1
$0
haloperidol tab 5mg
1
$0
loxapine cap 10mg
1
$0
loxapine cap 25mg
1
$0
loxapine cap 50mg
1
$0
loxapine cap 5mg
1
$0
ORAP TAB 1MG
2
$0
ORAP TAB 2MG
2
$0
perphen/amit tab 210mg
1
$0
PA
perphen/amit tab 225mg
1
$0
PA
perphen/amit tab 410mg
1
$0
PA
perphen/amit tab 425mg
1
$0
PA
perphen/amit tab 450mg
1
$0
PA
perphenazine tab
16mg
1
$0
perphenazine tab
2mg
1
$0
perphenazine tab
4mg
1
$0
perphenazine tab
8mg
1
$0
prochlorper inj
10mg/2ml
2
$0
prochlorper sup 25mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
66
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
prochlorper tab 10mg
1
$0
prochlorper tab 5mg
1
$0
thioridazine tab
100mg
1
$0
PA
thioridazine tab 10mg
1
$0
PA
thioridazine tab 25mg
1
$0
PA
thioridazine tab 50mg
1
$0
PA
thiothixene cap 10mg
1
$0
thiothixene cap 1mg
1
$0
thiothixene cap 2mg
1
$0
thiothixene cap 5mg
1
$0
trifluoperaz tab 10mg
1
$0
trifluoperaz tab 1mg
1
$0
trifluoperaz tab 2mg
1
$0
trifluoperaz tab 5mg
1
$0
ABILIFY DISC TAB
10MG
2
$0
ABILIFY DISC TAB
15MG
2
$0
ABILIFY INJ 9.75MG
2
$0
ABILIFY MAIN INJ
300MG
2
$0
ABILIFY MAIN INJ
300MG
2
$0
ABILIFY MAIN INJ
400MG
2
$0
ABILIFY TAB 10MG
2
$0
ABILIFY TAB 15MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
67
Name of Drug
Tier level
What the drug will
cost you
ABILIFY TAB 20MG
2
$0
ABILIFY TAB 2MG
2
$0
ABILIFY TAB 30MG
2
$0
ABILIFY TAB 5MG
2
$0
FANAPT PAK
2
$0
FANAPT TAB 10MG
2
$0
FANAPT TAB 12MG
2
$0
FANAPT TAB 1MG
2
$0
FANAPT TAB 2MG
2
$0
FANAPT TAB 4MG
2
$0
FANAPT TAB 6MG
2
$0
FANAPT TAB 8MG
2
$0
GEODON INJ 20MG
2
$0
INVEGA SUST INJ
117/0.75
2
$0
INVEGA SUST INJ
156MG/ML
2
$0
INVEGA SUST INJ
234/1.5
2
$0
INVEGA SUST INJ
39/0.25
2
$0
INVEGA SUST INJ
78/0.5ML
2
$0
INVEGA TAB 1.5MG
2
$0
INVEGA TAB 3MG
2
$0
INVEGA TAB 6MG
2
$0
INVEGA TAB 9MG
2
$0
Necessary actions,
restrictions, or limits
on use
LATUDA TAB 120MG 2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
68
Name of Drug
Tier level
What the drug will
cost you
LATUDA TAB 20MG
2
$0
LATUDA TAB 40MG
2
$0
LATUDA TAB 60MG
2
$0
LATUDA TAB 80MG
2
$0
olanzapine inj 10mg
1
$0
olanzapine tab 10mg
1
$0
olanzapine tab 10mg
odt
1
$0
olanzapine tab 15mg
1
$0
olanzapine tab 15mg
odt
1
$0
olanzapine tab 2.5mg
1
$0
olanzapine tab 20mg
1
$0
olanzapine tab 20mg
odt
1
$0
olanzapine tab 5mg
1
$0
olanzapine tab 5mg
odt
1
$0
olanzapine tab 7.5mg
1
$0
quetiapine tab 100mg
1
$0
quetiapine tab 200mg
1
$0
quetiapine tab 25mg
1
$0
quetiapine tab 300mg
1
$0
quetiapine tab 400mg
1
$0
quetiapine tab 50mg
1
$0
RISPERDAL INJ
12.5MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
69
Name of Drug
Tier level
What the drug will
cost you
RISPERDAL INJ
25MG
2
$0
RISPERDAL INJ
37.5MG
2
$0
RISPERDAL INJ
50MG
2
$0
risperidone sol
1mg/ml
1
$0
risperidone tab 0.25
odt
1
$0
risperidone tab
0.25mg
1
$0
risperidone tab 0.5mg
1
$0
risperidone tab 0.5mg
od
1
$0
risperidone tab 1mg
1
$0
risperidone tab 1mg
odt
1
$0
risperidone tab 2mg
1
$0
risperidone tab 2mg
odt
1
$0
risperidone tab 3mg
1
$0
risperidone tab 3mg
odt
1
$0
risperidone tab 4mg
1
$0
risperidone tab 4mg
odt
1
$0
SAPHRIS SUB 10MG
2
$0
SAPHRIS SUB 5MG
2
$0
SEROQUEL XR TAB
150MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
70
Name of Drug
Tier level
What the drug will
cost you
SEROQUEL XR TAB
200MG
2
$0
SEROQUEL XR TAB
300MG
2
$0
SEROQUEL XR TAB
400MG
2
$0
SEROQUEL XR TAB
50MG
2
$0
ziprasidone cap 20mg
1
$0
ziprasidone cap 40mg
1
$0
ziprasidone cap 60mg
1
$0
ziprasidone cap 80mg
1
$0
CLOZAPINE TAB
100/ODT
2
$0
clozapine tab 100mg
1
$0
CLOZAPINE TAB
12.5/ODT
2
$0
clozapine tab 200mg
1
$0
clozapine tab 25mg
1
$0
CLOZAPINE TAB
25MG ODT
2
$0
clozapine tab 50mg
1
$0
FAZACLO TAB
150MG
2
$0
FAZACLO TAB
200MG
2
$0
VERSACLOZ SUS
50MG/ML
2
$0
Necessary actions,
restrictions, or limits
on use
Antivirals
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
71
Name of Drug
Tier level
What the drug will
cost you
foscarnet inj 24mg/ml
1
$0
ganciclovir inj 500mg
1
$0
VALCYTE SOL
50MG/ML
2
$0
valganciclov tab
450mg
1
$0
ATRIPLA TAB
2
$0
COMPLERA TAB
2
$0
EDURANT TAB
25MG
2
$0
INTELENCE TAB
100MG
2
$0
INTELENCE TAB
200MG
2
$0
INTELENCE TAB
25MG
2
$0
NEVIRAPINE SUS
50MG/5ML
2
$0
nevirapine tab 200mg
1
$0
nevirapine tab 400mg
er
1
$0
RESCRIPTOR TAB
100 MG
2
$0
RESCRIPTOR TAB
200MG
2
$0
SUSTIVA CAP
200MG
2
$0
SUSTIVA CAP 50MG
2
$0
SUSTIVA TAB
600MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
72
Name of Drug
Tier level
What the drug will
cost you
VIRAMUNE XR TAB
100MG
2
$0
abacav/lamiv tab
/zidovud
1
$0
abacavir tab 300mg
1
$0
desloratadin tab 5mg
odt
1
$0
didanosine cap
125mg
1
$0
didanosine cap
200mg
1
$0
didanosine cap
250mg
1
$0
didanosine cap
400mg
1
$0
EMTRIVA CAP
200MG
2
$0
EMTRIVA SOL
10MG/ML
2
$0
EPIVIR HBV SOL
5MG/ML
2
$0
EPZICOM TAB 600300
2
$0
EVOTAZ TAB 300150
2
$0
lamivud/zido tab 150300
1
$0
lamivudine sol
10mg/ml
1
$0
lamivudine tab 100mg
1
$0
lamivudine tab 150mg
1
$0
Necessary actions,
restrictions, or limits
on use
lamivudine tab 300mg 1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
73
Name of Drug
Tier level
What the drug will
cost you
PREZCOBIX TAB
800-150
2
$0
RETROVIR INJ
10MG/ML
2
$0
stavudine cap 15mg
1
$0
stavudine cap 20mg
1
$0
stavudine cap 30mg
1
$0
stavudine cap 40mg
1
$0
TRIUMEQ TAB
2
$0
TRUVADA TAB 200300
2
$0
VIDEX SOL 2GM
2
$0
VIREAD POW
40MG/GM
2
$0
VIREAD TAB 150MG
2
$0
VIREAD TAB 200MG
2
$0
VIREAD TAB 250MG
2
$0
VIREAD TAB 300MG
2
$0
ZIAGEN SOL
20MG/ML
2
$0
zidovudine cap
100mg
1
$0
zidovudine syp
50mg/5ml
1
$0
zidovudine tab 300mg
1
$0
FUZEON INJ 90MG
2
$0
ISENTRESS CHW
100MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
74
Name of Drug
Tier level
What the drug will
cost you
ISENTRESS CHW
25MG
2
$0
ISENTRESS POW
100MG
2
$0
ISENTRESS TAB
400MG
2
$0
SELZENTRY TAB
150MG
2
$0
SELZENTRY TAB
300MG
2
$0
STRIBILD TAB
2
$0
TIVICAY TAB 50MG
2
$0
TYBOST TAB 150MG
2
$0
VITEKTA TAB
150MG
2
$0
VITEKTA TAB 85MG
2
$0
APTIVUS CAP
250MG
2
$0
APTIVUS SOL
2
$0
CRIXIVAN CAP
200MG
2
$0
CRIXIVAN CAP
400MG
2
$0
INVIRASE CAP
200MG
2
$0
INVIRASE TAB
500MG
2
$0
KALETRA SOL
2
$0
KALETRA TAB 10025MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
75
Name of Drug
Tier level
What the drug will
cost you
KALETRA TAB 20050MG
2
$0
LEXIVA SUS
50MG/ML
2
$0
LEXIVA TAB 700MG
2
$0
NORVIR CAP 100MG
2
$0
NORVIR SOL
80MG/ML
2
$0
NORVIR TAB 100MG
2
$0
PREZISTA SUS
100MG/ML
2
$0
PREZISTA TAB
150MG
2
$0
PREZISTA TAB
600MG
2
$0
PREZISTA TAB
75MG
2
$0
PREZISTA TAB
800MG
2
$0
REYATAZ CAP
150MG
2
$0
REYATAZ CAP
200MG
2
$0
REYATAZ CAP
300MG
2
$0
REYATAZ POW
50MG
2
$0
VIRACEPT TAB
250MG
2
$0
VIRACEPT TAB
625MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
76
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
RELENZA MIS
DISKHALE
2
$0
rimantadine tab
100mg
1
$0
TAMIFLU CAP 30MG
2
$0
TAMIFLU CAP 45MG
2
$0
TAMIFLU CAP 75MG
2
$0
TAMIFLU SUS
6MG/ML
2
$0
VIRAZOLE INH 6GM
2
$0
adefov dipiv tab 10mg
1
$0
BARACLUDE SOL
.05MG/ML
2
$0
entecavir tab 0.5mg
1
$0
entecavir tab 1mg
1
$0
HARVONI TAB 90400MG
2
$0
PA
OLYSIO CAP 150MG
2
$0
PA
PEGASYS INJ
2
$0
PEGASYS INJ
180MCG/M
2
$0
PEGASYS INJ
PROCLICK
2
$0
ribapak pak 1000/day
1
$0
ribapak pak 800/day
1
$0
ribasphere cap
200mg
1
$0
ribasphere tab 200mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
77
Name of Drug
Tier level
What the drug will
cost you
RIBASPHERE TAB
400MG
2
$0
ribavirin cap 200mg
1
$0
ribavirin tab 200mg
1
$0
SOVALDI TAB
400MG
2
$0
TYZEKA TAB 600MG
2
$0
VICTRELIS CAP
200MG
2
$0
acyclovir cap 200mg
1
$0
acyclovir na inj
50mg/ml
1
$0
acyclovir sus 200/5ml
1
$0
acyclovir tab 400mg
1
$0
acyclovir tab 800mg
1
$0
famciclovir tab 125mg
1
$0
famciclovir tab 250mg
1
$0
famciclovir tab 500mg
1
$0
valacyclovir tab 1gm
1
$0
valacyclovir tab
500mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
buspirone tab 10mg
1
$0
buspirone tab 15mg
1
$0
buspirone tab 30mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA
PA
PA
Anxiolytics
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
78
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
buspirone tab 5mg
1
$0
buspirone tab 7.5mg
1
$0
hydroxyz hcl inj
25mg/ml
1
$0
PA
hydroxyz hcl inj
50mg/ml
1
$0
PA
hydroxyz hcl sol
10mg/5ml
1
$0
PA
hydroxyz hcl tab
10mg
1
$0
PA
hydroxyz hcl tab
25mg
1
$0
PA
hydroxyz hcl tab
50mg
1
$0
PA
hydroxyz pam cap
100mg
1
$0
PA
hydroxyz pam cap
25mg
1
$0
PA
hydroxyz pam cap
50mg
1
$0
PA
meprobamate tab
200mg
1
$0
PA
meprobamate tab
400mg
1
$0
PA
ALPRAZOLAM CON
1 MG/ML
2
$0
alprazolam tab 0.25
odt
1
$0
alprazolam tab
0.25mg
1
$0
alprazolam tab 0.5mg
1
$0
QL (720)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
79
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
alprazolam tab 0.5mg
er
1
$0
QL (120)
alprazolam tab 0.5mg
od
1
$0
QL (180)
alprazolam tab 1mg
1
$0
alprazolam tab 1mg
er
1
$0
QL (120)
alprazolam tab 1mg
odt
1
$0
QL (360)
alprazolam tab 2mg
1
$0
alprazolam tab 2mg
er
1
$0
alprazolam tab 2mg
odt
1
$0
alprazolam tab 3mg
er
1
$0
QL (120)
chlordiazep cap 10mg
1
$0
QL (120)
chlordiazep cap 25mg
1
$0
QL (120)
chlordiazep cap 5mg
1
$0
QL (120)
cloraz dipot tab 15mg
1
$0
QL (120)
cloraz dipot tab
3.75mg
1
$0
QL (90)
cloraz dipot tab 7.5mg
1
$0
QL (90)
DIAZEPAM CON
5MG/ML
2
$0
QL (240)
DIAZEPAM SOL
1MG/ML
2
$0
QL (1200)
diazepam tab 10mg
1
$0
QL (120)
diazepam tab 2mg
1
$0
QL (600)
diazepam tab 5mg
1
$0
QL (240)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
80
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
lorazepam con
2mg/ml
1
$0
lorazepam tab 0.5mg
1
$0
QL (120)
lorazepam tab 1mg
1
$0
QL (90)
lorazepam tab 2mg
1
$0
QL (60)
oxazepam cap 10mg
1
$0
QL (120)
oxazepam cap 15mg
1
$0
QL (120)
oxazepam cap 30mg
1
$0
QL (120)
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
carbamazepin cap
100mg er
1
$0
carbamazepin chw
100mg
1
$0
lithium carb cap
150mg
1
$0
lithium carb cap
300mg
1
$0
lithium carb cap
600mg
1
$0
lithium carb tab
300mg
1
$0
lithium carb tab
300mg er
1
$0
lithium carb tab
450mg er
1
$0
lithium sol 8meq/5ml
1
$0
Bipolar Agents
Blood Glucose Regulators
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
81
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
acarbose tab 100mg
1
$0
acarbose tab 25mg
1
$0
acarbose tab 50mg
1
$0
ACTOPLUS MET
TAB XR
2
$0
ACTOPLUS MET
TAB XR
2
$0
AVANDAMET TAB 21000MG
2
$0
AVANDAMET TAB 2500MG
2
$0
AVANDAMET TAB 4500MG
2
$0
AVANDARYL TAB 41MG
2
$0
AVANDARYL TAB 42MG
2
$0
AVANDARYL TAB 84MG
2
$0
AVANDIA TAB 2MG
2
$0
AVANDIA TAB 4MG
2
$0
AVANDIA TAB 8MG
2
$0
BYETTA INJ 10MCG
2
$0
BYETTA INJ 5MCG
2
$0
chlorpropam tab
100mg
1
$0
PA
chlorpropam tab
250mg
1
$0
PA
CYCLOSET TAB
0.8MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
82
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
FARXIGA TAB 10MG
2
$0
FARXIGA TAB 5MG
2
$0
GAUZE PADS &
DRESSINGS - PADS
2
$0
glimepiride tab 1mg
1
$0
glimepiride tab 2mg
1
$0
glimepiride tab 4mg
1
$0
glip/metform tab 2.5250m
1
$0
glip/metform tab 2.5500m
1
$0
glip/metform tab 5500mg
1
$0
glipizide er tab 10mg
1
$0
glipizide er tab 2.5mg
1
$0
glipizide er tab 5mg
1
$0
glipizide tab 10mg
1
$0
glipizide tab 5mg
1
$0
GLUMETZA TAB
1000MG
2
$0
GLUMETZA TAB
500MG
2
$0
glyb/metform tab
1.25-250
1
$0
PA
glyb/metform tab 2.5500
1
$0
PA
glyb/metform tab 5500mg
1
$0
PA
glyburid mcr tab
1.5mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
83
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
glyburid mcr tab 3mg
1
$0
PA
glyburid mcr tab 6mg
1
$0
PA
glyburide tab 1.25mg
1
$0
PA
glyburide tab 2.5mg
1
$0
PA
glyburide tab 5mg
1
$0
PA
INSULIN PEN
NEEDLE
2
$0
INSULIN SYRINGE
(DISP) U-100
2
$0
INSULIN SYRINGE
(DISP) U-100
2
$0
INSULIN SYRINGE
(DISP) U-100
2
$0
INVOKAMET TAB
150-1000
2
$0
INVOKAMET TAB
150-500
2
$0
INVOKAMET TAB 501000
2
$0
INVOKAMET TAB 50500MG
2
$0
INVOKANA TAB
100MG
2
$0
INVOKANA TAB
300MG
2
$0
ISOPROPYL
ALCOHOL 0.7 ML/ML
2
$0
JANUMET TAB 501000
2
$0
JANUMET TAB 50500MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
84
Name of Drug
Tier level
What the drug will
cost you
JANUMET XR TAB
100-1000
2
$0
JANUMET XR TAB
50-1000
2
$0
JANUMET XR TAB
50-500MG
2
$0
JANUVIA TAB
100MG
2
$0
JANUVIA TAB 25MG
2
$0
JANUVIA TAB 50MG
2
$0
KAZANO 12.5- TAB
1000MG
2
$0
KAZANO 12.5- TAB
500MG
2
$0
KOMBIGLYZE TAB
2.5-1000
2
$0
KOMBIGLYZE TAB 52
1000MG
$0
KOMBIGLYZE TAB 5500MG
2
$0
metformin er tab
1000mg
1
$0
metformin tab
1000mg
1
$0
metformin tab 500mg
1
$0
metformin tab 500mg
er
1
$0
metformin tab 750mg
er
1
$0
metformin tab 850mg
1
$0
nateglinide tab 120mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
85
Name of Drug
Tier level
What the drug will
cost you
nateglinide tab 60mg
1
$0
NEEDLES, INSULIN
DISP., SAFET
2
$0
NESINA TAB 12.5MG
2
$0
NESINA TAB 25MG
2
$0
NESINA TAB 6.25MG
2
$0
ONGLYZA TAB
2.5MG
2
$0
ONGLYZA TAB 5MG
2
$0
OSENI TAB 12.5-15
2
$0
OSENI TAB 12.5-30
2
$0
OSENI TAB 12.5-45
2
$0
OSENI TAB 25-15MG
2
$0
OSENI TAB 25-30MG
2
$0
OSENI TAB 25-45MG
2
$0
pioglit/glim tab 304mg
1
$0
pioglita/met tab 15500mg
1
$0
pioglita/met tab 15850mg
1
$0
pioglitazone tab 15mg
1
$0
pioglitazone tab 30mg
1
$0
pioglitazone tab 45mg
1
$0
PRANDIMET TAB 1500MG
2
$0
PRANDIMET TAB 2500MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
86
Name of Drug
Tier level
What the drug will
cost you
PRANDIN TAB
0.5MG
2
$0
PRANDIN TAB 1MG
2
$0
PRANDIN TAB 2MG
2
$0
repaglinide tab 0.5mg
1
$0
repaglinide tab 1mg
1
$0
repaglinide tab 2mg
1
$0
RIOMET SOL
2
$0
SYMLINPEN 60 INJ
1000MCG
2
$0
SYMLNPEN 120 INJ
1000MCG
2
$0
tolazamide tab 250mg
1
$0
tolazamide tab 500mg
1
$0
tolbutamide tab
500mg
1
$0
valsart/hctz tab 16012.5
1
$0
GLUCAGEN INJ
HYPOKIT
2
$0
GLUCAGON KIT
1MG
2
$0
insta-glucos gel 40%
3
$0
PROGLYCEM SUS
50MG/ML
2
$0
SM GLUCOSE CHW
RASPBERY
3
$0
APIDRA INJ
SOLOSTAR
2
$0
APIDRA INJ U-100
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
87
Name of Drug
Tier level
What the drug will
cost you
LANTUS INJ 100/ML
2
$0
LANTUS INJ
SOLOSTAR
2
$0
LEVEMIR INJ
2
$0
LEVEMIR INJ
FLEXTOUC
2
$0
NOVOLIN INJ 70/30
2
$0
NOVOLIN N INJ U100
2
$0
NOVOLIN R INJ U100
2
$0
NOVOLOG INJ
100/ML
2
$0
NOVOLOG INJ
FLEXPEN
2
$0
NOVOLOG MIX INJ
70/30
2
$0
NOVOLOG MIX INJ
FLEXPEN
2
$0
Necessary actions,
restrictions, or limits
on use
Blood Products/Modifiers/ Volume Expanders
Name of Drug
Tier level
What the drug will
cost you
enoxaparin inj
100mg/ml
1
$0
enoxaparin inj 120/0.8
1
$0
enoxaparin inj
150mg/ml
1
$0
enoxaparin inj
30/0.3ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
88
Name of Drug
Tier level
What the drug will
cost you
enoxaparin inj
300/3ml
1
$0
enoxaparin inj
40/0.4ml
1
$0
enoxaparin inj
60/0.6ml
1
$0
enoxaparin inj
80/0.8ml
1
$0
fondaparinux sol
10/0.8
1
$0
fondaparinux sol
2.5/0.5
1
$0
fondaparinux sol
5.0/0.4
1
$0
fondaparinux sol
7.5/0.6
1
$0
FRAGMIN INJ
7500/0.3
2
$0
FRAGMIN INJ
95000UNT
2
$0
hep sod/d5w inj
20000unt
1
$0
hep sod/d5w inj
25000unt
1
$0
hep sod/d5w inj
25000unt
1
$0
heparin sod inj
1000/ml
1
$0
heparin sod inj
10000/ml
1
$0
heparin sod inj
20000/ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
89
Name of Drug
Tier level
What the drug will
cost you
heparin sod inj
5000/ml
1
$0
jantoven tab 10mg
1
$0
jantoven tab 1mg
1
$0
jantoven tab 2.5mg
1
$0
jantoven tab 2mg
1
$0
jantoven tab 3mg
1
$0
jantoven tab 4mg
1
$0
jantoven tab 5mg
1
$0
jantoven tab 6mg
1
$0
jantoven tab 7.5mg
1
$0
PRADAXA CAP
150MG
2
$0
PRADAXA CAP
75MG
2
$0
warfarin tab 10mg
1
$0
warfarin tab 1mg
1
$0
warfarin tab 2.5mg
1
$0
warfarin tab 2mg
1
$0
warfarin tab 3mg
1
$0
warfarin tab 4mg
1
$0
warfarin tab 5mg
1
$0
warfarin tab 6mg
1
$0
warfarin tab 7.5mg
1
$0
XARELTO STAR TAB
15/20MG
2
$0
XARELTO TAB 10MG 2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
90
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
XARELTO TAB 15MG 2
$0
XARELTO TAB 20MG 2
$0
LEUKINE INJ
250MCG
2
$0
MIRCERA INJ
100MCG
2
$0
PA
MIRCERA INJ
50MCG
2
$0
PA
MIRCERA INJ
75MCG
2
$0
PA
MOZOBIL INJ
2
$0
NEUMEGA INJ 5MG
2
$0
NEUPOGEN INJ
300/0.5
2
$0
NEUPOGEN INJ
480/0.8
2
$0
NEUPOGEN INJ
480MCG
2
$0
PROCRIT INJ
10000/ML
2
$0
PA, QL (12/28)
PROCRIT INJ
2000/ML
2
$0
PA, QL (23)
PROCRIT INJ
20000/ML
2
$0
PA, QL (12/28)
PROCRIT INJ
3000/ML
2
$0
PA, QL (16)
PROCRIT INJ
4000/ML
2
$0
PA, QL (12/28)
PROCRIT INJ
40000/ML
2
$0
PA, QL (12)
PROMACTA TAB
12.5MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
91
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
PROMACTA TAB
25MG
2
$0
PROMACTA TAB
50MG
2
$0
PROMACTA TAB
75MG
2
$0
tranex acid inj
100mg/ml
1
$0
tranex acid tab 650mg 1
$0
AGGRENOX CAP 25200MG
2
$0
anagrelide cap 0.5mg
1
$0
BRILINTA TAB 90MG
2
$0
cilostazol tab 100mg
1
$0
cilostazol tab 50mg
1
$0
clopidogrel tab 300mg
1
$0
clopidogrel tab 75mg
1
$0
dipyridamole tab
25mg
1
$0
PA
dipyridamole tab
50mg
1
$0
PA
dipyridamole tab
75mg
1
$0
PA
EFFIENT TAB 10MG
2
$0
EFFIENT TAB 5MG
2
$0
ticlopidine tab 250mg
1
$0
PA
Cardiovascular Agents
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
92
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
clonidine tab 0.1mg
1
$0
clonidine tab 0.2mg
1
$0
clonidine tab 0.3mg
1
$0
methyldopa tab
250mg
1
$0
PA
methyldopa tab
500mg
1
$0
PA
methyldopate inj
250/5ml
1
$0
PA
midodrine tab 10mg
1
$0
midodrine tab 2.5mg
1
$0
midodrine tab 5mg
1
$0
doxazosin tab 1mg
1
$0
doxazosin tab 2mg
1
$0
doxazosin tab 4mg
1
$0
doxazosin tab 8mg
1
$0
prazosin hcl cap 1mg
1
$0
prazosin hcl cap 2mg
1
$0
prazosin hcl cap 5mg
1
$0
terazosin cap 10mg
1
$0
terazosin cap 1mg
1
$0
terazosin cap 2mg
1
$0
terazosin cap 5mg
1
$0
ATACAND TAB
16MG
2
$0
ATACAND TAB
32MG
2
$0
BENICAR TAB 20MG 2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
93
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
BENICAR TAB 40MG
2
$0
BENICAR TAB 5MG
2
$0
candesartan tab
16mg
1
$0
candesartan tab
32mg
1
$0
candesartan tab 4mg
1
$0
candesartan tab 8mg
1
$0
EDARBI TAB 40MG
2
$0
ST
EDARBI TAB 80MG
2
$0
ST
eprosart mes tab
600mg
1
$0
irbesartan tab 150mg
1
$0
irbesartan tab 300mg
1
$0
irbesartan tab 75mg
1
$0
losartan pot tab
100mg
1
$0
losartan pot tab 25mg
1
$0
losartan pot tab 50mg
1
$0
telmisartan tab 20mg
1
$0
telmisartan tab 40mg
1
$0
telmisartan tab 80mg
1
$0
benazepril tab 10mg
1
$0
benazepril tab 20mg
1
$0
benazepril tab 40mg
1
$0
benazepril tab 5mg
1
$0
captopril tab 100mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
94
Name of Drug
Tier level
What the drug will
cost you
captopril tab 12.5mg
1
$0
captopril tab 25mg
1
$0
captopril tab 50mg
1
$0
enalapril tab 10mg
1
$0
enalapril tab 2.5mg
1
$0
enalapril tab 20mg
1
$0
enalapril tab 5mg
1
$0
fosinopril tab 10mg
1
$0
fosinopril tab 20mg
1
$0
fosinopril tab 40mg
1
$0
lisinopril tab 10mg
1
$0
lisinopril tab 2.5mg
1
$0
lisinopril tab 20mg
1
$0
lisinopril tab 30mg
1
$0
lisinopril tab 40mg
1
$0
lisinopril tab 5mg
1
$0
moexipril tab 15mg
1
$0
moexipril tab 7.5mg
1
$0
perindopril tab 2mg
1
$0
perindopril tab 4mg
1
$0
perindopril tab 8mg
1
$0
quinapril tab 10mg
1
$0
quinapril tab 20mg
1
$0
quinapril tab 40mg
1
$0
quinapril tab 5mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
95
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ramipril cap 1.25mg
1
$0
ramipril cap 10mg
1
$0
ramipril cap 2.5mg
1
$0
ramipril cap 5mg
1
$0
trandolapril tab 1mg
1
$0
trandolapril tab 2mg
1
$0
trandolapril tab 4mg
1
$0
amiodarone inj
50mg/ml
1
$0
amiodarone tab
200mg
1
$0
amiodarone tab
400mg
1
$0
disopyramide cap
100mg
1
$0
PA
disopyramide cap
150mg
1
$0
PA
flecainide tab 100mg
1
$0
flecainide tab 150mg
1
$0
flecainide tab 50mg
1
$0
mexiletine cap 150mg
1
$0
mexiletine cap 200mg
1
$0
mexiletine cap 250mg
1
$0
MULTAQ TAB
400MG
2
$0
pacerone tab 100mg
1
$0
pacerone tab 200mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
96
Name of Drug
Tier level
What the drug will
cost you
procainamide inj
100mg/ml
1
$0
propafenone tab
150mg
1
$0
propafenone tab
225mg
1
$0
propafenone tab
300mg
1
$0
quinidine gl tab
324mg cr
1
$0
quinidine su tab
200mg
1
$0
quinidine su tab
300mg
1
$0
quinidine su tab
300mg er
1
$0
TIKOSYN CAP
125MCG
2
$0
TIKOSYN CAP
250MCG
2
$0
TIKOSYN CAP
500MCG
2
$0
amilor/hctz tab 5-50
1
$0
amlod/benazp cap 1020mg
1
$0
amlod/benazp cap 1040mg
1
$0
amlod/benazp cap
2.5-10mg
1
$0
amlod/benazp cap 510mg
1
$0
Necessary actions,
restrictions, or limits
on use
amlod/benazp cap 520mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
97
Name of Drug
Tier level
What the drug will
cost you
amlod/benazp cap 540mg
1
$0
amlod/valsar tab /hctz
2
$0
amlod/valsar tab /hctz
2
$0
amlod/valsar tab /hctz
2
$0
amlod/valsar tab /hctz
2
$0
amlod/valsar tab /hctz
2
$0
amlod/valsar tab 10160mg
2
$0
amlod/valsar tab 10320mg
2
$0
amlod/valsar tab 5160mg
2
$0
amlod/valsar tab 5320mg
2
$0
atenol/chlor tab 10025mg
1
$0
atenol/chlor tab 5025mg
1
$0
AZOR TAB 10-20MG
2
$0
AZOR TAB 10-40MG
2
$0
AZOR TAB 5-20MG
2
$0
AZOR TAB 5-40MG
2
$0
benazep/hctz tab 1012.5
1
$0
benazep/hctz tab 2012.5
1
$0
benazep/hctz tab 2025mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
98
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
benazep/hctz tab 56.25
1
$0
BENICAR HCT TAB
20-12.5
2
$0
BENICAR HCT TAB
40-12.5
2
$0
BENICAR HCT TAB
40-25MG
2
$0
bisoprl/hctz tab
10/6.25
1
$0
bisoprl/hctz tab
2.5/6.25
1
$0
bisoprl/hctz tab 56.25mg
1
$0
candesa/hctz tab 1612.5
1
$0
candesa/hctz tab 3212.5
1
$0
candesa/hctz tab 3225mg
1
$0
captopr/hctz tab 2515mg
1
$0
captopr/hctz tab 2525mg
1
$0
captopr/hctz tab 5015mg
1
$0
captopr/hctz tab 5025mg
1
$0
EDARBYCLOR TAB
40-12.5
2
$0
ST
EDARBYCLOR TAB
40-25MG
2
$0
ST
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
99
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
enalapr/hctz tab 1025mg
1
$0
enalapr/hctz tab 512.5mg
1
$0
fosinop/hctz tab
10/12.5
1
$0
fosinop/hctz tab
20/12.5
1
$0
lisinop/hctz tab 1012.5
1
$0
lisinop/hctz tab 2012.5
1
$0
lisinop/hctz tab 2025mg
1
$0
losartan/hct tab 10012.5
1
$0
losartan/hct tab 10025
1
$0
losartan/hct tab 5012.5
1
$0
methyld/hctz tab
250/15
1
$0
PA
methyld/hctz tab
250/25
1
$0
PA
metoprl/hctz tab 10025mg
1
$0
metoprl/hctz tab 10050mg
1
$0
metoprl/hctz tab 5025mg
1
$0
moexipr/hctz tab 1512.5
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
100
Name of Drug
Tier level
What the drug will
cost you
moexipr/hctz tab 1525mg
1
$0
moexipr/hctz tab 7.512.5
1
$0
nadolol/bend tab 405mg
1
$0
nadolol/bend tab 805mg
1
$0
pioglit/glim tab 302mg
1
$0
propran/hctz tab
40/25
1
$0
propran/hctz tab
80/25
1
$0
qnapril/hctz tab 1012.5
1
$0
qnapril/hctz tab 2012.5
1
$0
qnapril/hctz tab 2025mg
1
$0
spirono/hctz tab 25/25
1
$0
TARKA TAB 1-240
CR
2
$0
TARKA TAB 2-180
CR
2
$0
TARKA TAB 2-240
CR
2
$0
TARKA TAB 4-240
CR
2
$0
TEKAMLO TAB 15010MG
2
$0
Necessary actions,
restrictions, or limits
on use
TEKAMLO TAB 1505MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
101
Name of Drug
Tier level
What the drug will
cost you
TEKAMLO TAB 30010MG
2
$0
TEKAMLO TAB 3005MG
2
$0
TEKTURNA HCT
TAB 150-12.5
2
$0
TEKTURNA HCT
TAB 150-25MG
2
$0
TEKTURNA HCT
TAB 300-12.5
2
$0
TEKTURNA HCT
TAB 300-25MG
2
$0
telmis/amlod tab 4010mg
1
$0
telmis/amlod tab 405mg
1
$0
telmis/amlod tab 8010mg
1
$0
telmis/amlod tab 805mg
1
$0
TEVETEN HCT TAB
600-12.5
2
$0
TEVETEN HCT TAB
600-25MG
2
$0
trando/verap tab 1240 cr
1
$0
trando/verap tab 2180 cr
1
$0
trando/verap tab 2240 cr
1
$0
trando/verap tab 4240 cr
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
102
Name of Drug
Tier level
What the drug will
cost you
triamt/hctz cap 5025mg
1
$0
triamt/hctz tab 37.525
1
$0
triamt/hctz tab 7550mg
1
$0
TRIBENZOR20- TAB
5-12.5MG
2
$0
TRIBENZOR40- TAB
10-12.5
2
$0
TRIBENZOR40- TAB
10-25MG
2
$0
TRIBENZOR40- TAB
5-12.5MG
2
$0
TRIBENZOR40- TAB
5-25MG
2
$0
valsart/hctz tab 16025mg
1
$0
valsart/hctz tab 32012.5
1
$0
valsart/hctz tab 32025mg
1
$0
valsart/hctz tab 8012.5
1
$0
acebutolol cap 200mg
1
$0
acebutolol cap 400mg
1
$0
atenolol tab 100mg
1
$0
atenolol tab 25mg
1
$0
atenolol tab 50mg
1
$0
betaxolol tab 10mg
1
$0
betaxolol tab 20mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
103
Name of Drug
Tier level
What the drug will
cost you
bisoprol fum tab 10mg 1
$0
bisoprol fum tab 5mg
1
$0
carvedilol tab 12.5mg
1
$0
carvedilol tab 25mg
1
$0
carvedilol tab
3.125mg
1
$0
carvedilol tab 6.25mg
1
$0
labetalol inj 5mg/ml
1
$0
labetalol tab 100mg
1
$0
labetalol tab 200mg
1
$0
labetalol tab 300mg
1
$0
metoprol tar tab
100mg
1
$0
metoprol tar tab 25mg
1
$0
metoprol tar tab 50mg
1
$0
metoprolol inj 1mg/ml
1
$0
metoprolol tab 100mg
er
1
$0
metoprolol tab 200mg
er
1
$0
metoprolol tab 25mg
er
1
$0
metoprolol tab 50mg
er
1
$0
nadolol tab 20mg
1
$0
nadolol tab 40mg
1
$0
nadolol tab 80mg
1
$0
pindolol tab 10mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
104
Name of Drug
Tier level
What the drug will
cost you
pindolol tab 5mg
1
$0
propranolol cap
120mg er
1
$0
propranolol cap
160mg er
1
$0
propranolol cap 60mg
er
1
$0
propranolol cap 80mg
er
1
$0
propranolol inj 1mg/ml
1
$0
propranolol sol
20mg/5ml
1
$0
propranolol sol
40mg/5ml
1
$0
propranolol tab 10mg
1
$0
propranolol tab 20mg
1
$0
propranolol tab 40mg
1
$0
propranolol tab 60mg
1
$0
propranolol tab 80mg
1
$0
sorine tab 120mg
1
$0
sorine tab 160mg
1
$0
sorine tab 240mg
1
$0
sorine tab 80mg
1
$0
sotalol af tab 120mg
1
$0
sotalol hcl tab 160mg
1
$0
sotalol hcl tab 240mg
1
$0
sotalol hcl tab 80mg
1
$0
timolol mal tab 10mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
105
Name of Drug
Tier level
What the drug will
cost you
timolol mal tab 20mg
1
$0
timolol mal tab 5mg
1
$0
afeditab tab 30mg cr
1
$0
afeditab tab 60mg cr
1
$0
amlodipine tab 10mg
1
$0
amlodipine tab 2.5mg
1
$0
amlodipine tab 5mg
1
$0
cartia xt cap 120/24hr
1
$0
cartia xt cap 180/24hr
1
$0
cartia xt cap 240/24hr
1
$0
cartia xt cap 300/24hr
1
$0
dilt-xr cap 120mg
1
$0
dilt-xr cap 180mg
1
$0
dilt-xr cap 240mg
1
$0
diltiazem cap 120mg
er
1
$0
diltiazem cap 120mg
er
1
$0
diltiazem cap
180mg/24
1
$0
diltiazem cap 240mg
cd
1
$0
diltiazem cap 300mg
er
1
$0
diltiazem cap
360mg/24
1
$0
diltiazem cap
420mg/24
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
106
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
diltiazem cap 60mg er
1
$0
diltiazem cap 90mg er
1
$0
diltiazem inj 100mg
1
$0
diltiazem inj 50/10ml
1
$0
diltiazem tab 120mg
1
$0
diltiazem tab 30mg
1
$0
diltiazem tab 60mg
1
$0
diltiazem tab 90mg
1
$0
felodipine tab 10mg er 1
$0
felodipine tab 2.5mg
er
1
$0
felodipine tab 5mg er
1
$0
isradipine cap 2.5mg
1
$0
isradipine cap 5mg
1
$0
nicardipine cap 20mg
1
$0
nicardipine cap 30mg
1
$0
nifedical xl tab 30mg
1
$0
nifedical xl tab 60mg
1
$0
nifedipine cap 10mg
1
$0
PA
nifedipine cap 20mg
1
$0
PA
nifedipine tab 30mg er 1
$0
nifedipine tab 60mg er 1
$0
nifedipine tab 90mg er 1
$0
nimodipine cap 30mg
1
$0
nisoldipine tab 20mg
1
$0
nisoldipine tab 30mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
107
Name of Drug
Tier level
What the drug will
cost you
nisoldipine tab 40mg
1
$0
taztia xt cap
120mg/24
1
$0
taztia xt cap
180mg/24
1
$0
taztia xt cap
240mg/24
1
$0
taztia xt cap
300mg/24
1
$0
taztia xt cap
360mg/24
1
$0
verapamil cap 100mg
er
1
$0
verapamil cap 120mg
er
1
$0
verapamil cap 180mg
er
1
$0
verapamil cap 200mg
er
1
$0
verapamil cap 240mg
er
1
$0
verapamil cap 300mg
er
1
$0
verapamil cap 360mg
sr
1
$0
verapamil inj
2.5mg/ml
1
$0
verapamil tab 120mg
1
$0
verapamil tab 120mg
er
1
$0
verapamil tab 180mg
er
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
108
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
verapamil tab 240mg
er
1
$0
verapamil tab 40mg
1
$0
verapamil tab 80mg
1
$0
digitek tab 0.125mg
1
$0
PA
digitek tab 0.25mg
1
$0
PA
digoxin inj 0.25mg/1
1
$0
digoxin sol 50mcg/ml
1
$0
digoxin tab 0.125mg
1
$0
PA, QL (30)
digoxin tab 0.25mg
1
$0
PA
NORTHERA CAP
100MG
2
$0
PA
NORTHERA CAP
200MG
2
$0
PA
NORTHERA CAP
300MG
2
$0
PA
pentoxifylli tab 400mg
er
1
$0
RANEXA TAB
1000MG
2
$0
RANEXA TAB 500MG 2
$0
reserpine tab 0.1mg
1
$0
TEKTURNA TAB
150MG
2
$0
TEKTURNA TAB
300MG
2
$0
acetazolamid cap
500mg er
1
$0
acetazolamid tab
125mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
109
Name of Drug
Tier level
What the drug will
cost you
acetazolamid tab
250mg
1
$0
methazolamid tab
25mg
1
$0
methazolamid tab
50mg
1
$0
bumetanide inj
0.25/ml
1
$0
bumetanide tab
0.5mg
1
$0
bumetanide tab 1mg
1
$0
bumetanide tab 2mg
1
$0
furosemide inj
10mg/ml
1
$0
furosemide sol
10mg/ml
1
$0
furosemide sol
8mg/ml
1
$0
furosemide tab 20mg
1
$0
furosemide tab 40mg
1
$0
furosemide tab 80mg
1
$0
torsemide tab 100mg
1
$0
torsemide tab 10mg
1
$0
torsemide tab 20mg
1
$0
torsemide tab 5mg
1
$0
amiloride tab 5mg
1
$0
DEMSER CAP
250MG
2
$0
DYRENIUM CAP
100MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
110
Name of Drug
Tier level
What the drug will
cost you
DYRENIUM CAP
50MG
2
$0
eplerenone tab 25mg
1
$0
eplerenone tab 50mg
1
$0
spironolact tab 100mg
1
$0
spironolact tab 25mg
1
$0
spironolact tab 50mg
1
$0
chlorothiaz tab 250mg
1
$0
chlorothiaz tab 500mg
1
$0
chlorthalid tab 25mg
1
$0
CHLORTHALID TAB
50MG
2
$0
hydrochlorot cap
12.5mg
1
$0
hydrochlorot tab
12.5mg
1
$0
hydrochlorot tab
25mg
1
$0
hydrochlorot tab
50mg
1
$0
indapamide tab
1.25mg
1
$0
indapamide tab 2.5mg 1
$0
methyclothia tab 5mg
1
$0
metolazone tab 10mg
1
$0
metolazone tab 2.5mg 1
$0
metolazone tab 5mg
1
$0
VYTORIN TAB 1010MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
111
Name of Drug
Tier level
What the drug will
cost you
VYTORIN TAB 1020MG
2
$0
VYTORIN TAB 1040MG
2
$0
VYTORIN TAB 1080MG
2
$0
fenofibrate cap
134mg
1
$0
fenofibrate cap
150mg
1
$0
fenofibrate cap
200mg
1
$0
fenofibrate cap 50mg
1
$0
fenofibrate cap 67mg
1
$0
fenofibrate tab 145mg
1
$0
fenofibrate tab 160mg
1
$0
fenofibrate tab 48mg
1
$0
fenofibrate tab 54mg
1
$0
gemfibrozil tab 600mg
1
$0
ADVICOR TAB 100020
2
$0
ADVICOR TAB 100040
2
$0
ADVICOR TAB 50020MG
2
$0
ADVICOR TAB 75020MG
2
$0
ALTOPREV TAB
20MG ER
2
$0
ALTOPREV TAB
40MG ER
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
112
Name of Drug
Tier level
What the drug will
cost you
ALTOPREV TAB
60MG ER
2
$0
atorvastatin tab 10mg
1
$0
atorvastatin tab 20mg
1
$0
atorvastatin tab 40mg
1
$0
atorvastatin tab 80mg
1
$0
CRESTOR TAB
10MG
2
$0
CRESTOR TAB
20MG
2
$0
CRESTOR TAB
40MG
2
$0
CRESTOR TAB 5MG
2
$0
fluvastatin cap 20mg
1
$0
fluvastatin cap 40mg
1
$0
LESCOL XL TAB
80MG
2
$0
LIVALO TAB 1MG
2
$0
LIVALO TAB 2MG
2
$0
LIVALO TAB 4MG
2
$0
lovastatin tab 10mg
1
$0
lovastatin tab 20mg
1
$0
lovastatin tab 40mg
1
$0
pravastatin tab 10mg
1
$0
pravastatin tab 20mg
1
$0
pravastatin tab 40mg
1
$0
pravastatin tab 80mg
1
$0
Necessary actions,
restrictions, or limits
on use
simvastatin tab 10mg 1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
113
Name of Drug
Tier level
What the drug will
cost you
simvastatin tab 20mg
1
$0
simvastatin tab 40mg
1
$0
simvastatin tab 5mg
1
$0
simvastatin tab 80mg
1
$0
cholestyram pow 4gm
lite
1
$0
colestipol gra 5gm
1
$0
colestipol tab 1gm
1
$0
JUXTAPID CAP
10MG
2
$0
JUXTAPID CAP
20MG
2
$0
JUXTAPID CAP 5MG
2
$0
KYNAMRO INJ
200MG/ML
2
$0
niacin er tab 1000mg
1
$0
niacin er tab 500mg
1
$0
niacin er tab 750mg
1
$0
NIACOR TAB 500MG
2
$0
omega-3-acid cap
1gm
1
$0
prevalite pow 4gm
1
$0
WELCHOL PAK
3.75GM
2
$0
WELCHOL TAB
625MG
2
$0
ZETIA TAB 10MG
2
$0
hydralazine inj
20mg/ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
114
Name of Drug
Tier level
What the drug will
cost you
hydralazine tab
100mg
1
$0
hydralazine tab 10mg
1
$0
hydralazine tab 25mg
1
$0
hydralazine tab 50mg
1
$0
minoxidil tab 10mg
1
$0
minoxidil tab 2.5mg
1
$0
isosorb din tab 10mg
1
$0
isosorb din tab 20mg
1
$0
isosorb din tab 30mg
1
$0
isosorb din tab 40mg
er
1
$0
isosorb din tab 5mg
1
$0
isosorb mono tab
10mg
1
$0
isosorb mono tab
120mg er
1
$0
isosorb mono tab
20mg
1
$0
isosorb mono tab
30mg er
1
$0
isosorb mono tab
60mg er
1
$0
minitran dis 0.1mg/hr
1
$0
minitran dis 0.2mg/hr
1
$0
minitran dis 0.4mg/hr
1
$0
minitran dis 0.6mg/hr
1
$0
nitroglycer dis
0.1mg/hr
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
115
Name of Drug
Tier level
What the drug will
cost you
nitroglycer dis
0.2mg/hr
1
$0
nitroglycer dis
0.4mg/hr
1
$0
nitroglycer inj 5mg/ml
1
$0
nitroglyceri dis
0.6mg/hr
1
$0
nitroglycrn spr 0.4mg
1
$0
NITROSTAT SUB
0.3MG
2
$0
NITROSTAT SUB
0.4MG
2
$0
NITROSTAT SUB
0.6MG
2
$0
Necessary actions,
restrictions, or limits
on use
Central Nervous System Agents
Name of Drug
Tier level
What the drug will
cost you
amphetamine tab
10mg
1
$0
amphetamine tab
12.5mg
1
$0
amphetamine tab
15mg
1
$0
amphetamine tab
20mg
1
$0
amphetamine tab
30mg
1
$0
amphetamine tab
5mg
1
$0
Necessary actions,
restrictions, or limits
on use
amphetamine tab
7.5mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
116
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
dextroamphet cap
10mg er
1
$0
dextroamphet cap
15mg er
1
$0
dextroamphet cap
5mg er
1
$0
dextroamphet tab
10mg
1
$0
dextroamphet tab
5mg
1
$0
guanfacine tab 1mg
er
2
$0
PA
guanfacine tab 2mg
er
2
$0
PA
guanfacine tab 3mg
er
2
$0
PA
guanfacine tab 4mg
er
2
$0
PA
metadate tab 20mg er
1
$0
methylin chw 10mg
1
$0
methylin chw 2.5mg
1
$0
methylin chw 5mg
1
$0
methylphenid cap
10mg
1
$0
methylphenid sol
10mg/5ml
1
$0
methylphenid sol
5mg/5ml
1
$0
methylphenid tab
10mg
1
$0
methylphenid tab
20mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
117
Name of Drug
Tier level
What the drug will
cost you
methylphenid tab
20mg er
1
$0
methylphenid tab
27mg er
1
$0
methylphenid tab 5mg
1
$0
STRATTERA CAP
100MG
2
$0
STRATTERA CAP
10MG
2
$0
STRATTERA CAP
18MG
2
$0
STRATTERA CAP
25MG
2
$0
STRATTERA CAP
40MG
2
$0
STRATTERA CAP
60MG
2
$0
STRATTERA CAP
80MG
2
$0
NUEDEXTA CAP 2010MG
2
$0
riluzole tab 50mg
1
$0
XENAZINE TAB
12.5MG
2
$0
XENAZINE TAB
25MG
2
$0
LYRICA CAP 100MG
2
$0
LYRICA CAP 150MG
2
$0
SAVELLA MIS TITR
PAK
2
$0
Necessary actions,
restrictions, or limits
on use
PA
SAVELLA TAB
100MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
118
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
SAVELLA TAB
12.5MG
2
$0
SAVELLA TAB 25MG
2
$0
SAVELLA TAB 50MG
2
$0
AMPYRA TAB 10MG
2
$0
AUBAGIO TAB 14MG
2
$0
ST
AUBAGIO TAB 7MG
2
$0
ST
BETASERON INJ
0.3MG
2
$0
COPAXONE INJ
40MG/ML
2
$0
COPAXONE KIT
20MG/ML
2
$0
EXTAVIA INJ 0.3MG
2
$0
GILENYA CAP
0.5MG
2
$0
REBIF INJ 22/0.5
2
$0
REBIF INJ 44/0.5
2
$0
REBIF TITRTN SOL
PACK
2
$0
SOLTAMOX SOL
10MG/5ML
2
$0
TYSABRI INJ
300/15ML
2
$0
PA
Necessary actions,
restrictions, or limits
on use
Dental And Oral Agents
Name of Drug
Tier level
What the drug will
cost you
chlorhex glu sol
0.12%
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
119
Name of Drug
Tier level
What the drug will
cost you
nystatin sus 100000
1
$0
periogard sol 0.12%
1
$0
pilocarpine tab 5mg
1
$0
pilocarpine tab 7.5mg
1
$0
triamcin/ora pst 0.1%
1
$0
Necessary actions,
restrictions, or limits
on use
Dermatological Agents
Name of Drug
Tier level
What the drug will
cost you
8-MOP CAP 10MG
2
$0
ABREVA
10%
3
$0
acitretin cap 10mg
1
$0
acitretin cap 17.5mg
1
$0
acitretin cap 25mg
1
$0
acne medicat gel 10%
3
$0
acne medicat gel 5%
3
$0
ACNE MEDICAT LOT
10%
3
$0
ACNE MEDICAT LOT
5%
3
$0
ala cort cre 1%
1
$0
amcinonide cre 0.1%
1
$0
amcinonide lot 0.1%
1
$0
amcinonide oin 0.1%
1
$0
ammonium lac lot
12%
1
$0
Necessary actions,
restrictions, or limits
on use
CRE
amnesteem cap 10mg 1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
120
Name of Drug
Tier level
What the drug will
cost you
amnesteem cap 20mg 1
$0
amnesteem cap 40mg 1
$0
aug betamet lot
0.05%
1
$0
betameth dip cre
0.05%
1
$0
betameth dip oin
0.05%
1
$0
betameth val cre
0.1%
1
$0
betameth val lot 0.1%
1
$0
betameth val oin 0.1% 1
$0
calcipotrien sol
0.005%
1
$0
ciclopirox cre 0.77%
1
$0
ciclopirox gel 0.77%
1
$0
ciclopirox sol 8%
1
$0
ciclopirox sus 0.77%
1
$0
claravis cap 10mg
1
$0
claravis cap 20mg
1
$0
claravis cap 30mg
1
$0
claravis cap 40mg
1
$0
CLINDACIN KIT PAC
1%
2
$0
clindamy/ben gel 15%
1
$0
clindamycin gel 1%
1
$0
clindamycin lot 1%
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
121
Name of Drug
Tier level
What the drug will
cost you
clindamycin pad 1%
1
$0
clindamycin sol 1%
1
$0
clobetasol e cre
0.05%
1
$0
clobetasol gel 0.05%
1
$0
clobetasol oin 0.05%
1
$0
clobetasol sol 0.05%
1
$0
clotrim/beta cre diprop 1
$0
clotrim/beta lot diprop
1
$0
clotrimazole cre 1%
1
$0
clotrimazole sol 1%
1
$0
CONDYLOX GEL
0.5%
2
$0
cormax scalp sol
0.05%
1
$0
desonide cre 0.05%
1
$0
desonide lot 0.05%
1
$0
desonide oin 0.05%
1
$0
desoximetas cre
0.05%
1
$0
desoximetas cre
0.25%
1
$0
desoximetas gel
0.05%
1
$0
desoximetas oin
0.25%
1
$0
diclofenac gel 3%
1
$0
diflorasone cre 0.05%
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
122
Name of Drug
Tier level
What the drug will
cost you
diflorasone oin 0.05%
1
$0
econazole cre 1%
1
$0
ELIDEL CRE 1%
2
$0
erythromycin gel
/benzoyl
1
$0
erythromycin gel 2%
1
$0
erythromycin sol 2%
1
$0
EURAX CRE 10%
2
$0
fluocin acet cre 0.01%
1
$0
fluocin acet cre
0.025%
1
$0
fluocin acet oil body
1
$0
fluocin acet oin
0.025%
1
$0
fluocin acet sol 0.01%
1
$0
fluocinonide cre -e
0.05%
1
$0
fluocinonide gel
0.05%
1
$0
fluocinonide oin
0.05%
1
$0
fluocinonide sol
0.05%
1
$0
FLUOROURACIL
CRE 0.5%
2
$0
fluorouracil cre 5%
1
$0
fluticasone cre 0.05%
1
$0
fluticasone oin
0.005%
1
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
123
Name of Drug
Tier level
What the drug will
cost you
gentamicin cre 0.1%
1
$0
gentamicin oin 0.1%
1
$0
halobetasol cre 0.05% 1
$0
halobetasol oin 0.05%
1
$0
hc valerate cre 0.2%
1
$0
hc valerate oin 0.2%
1
$0
hydrocort cre 1%
1
$0
hydrocort cre 2.5%
1
$0
hydrocort lot 2.5%
1
$0
hydrocort oin 1%
1
$0
hydrocort oin 2.5%
1
$0
imiquimod cre 5%
1
$0
ketoconazole cre 2%
1
$0
ketoconazole sha 2%
1
$0
lidocaine gel 2% jelly
1
$0
lidocaine oin 5%
1
$0
lidocaine sol 4%
1
$0
LIDODERM DIS 5%
2
$0
lindane lot 1%
1
$0
lindane sha 1%
1
$0
lokara lot 0.05%
1
$0
methoxsalen cap
10mg
1
$0
metronidazol cre
0.75%
1
$0
metronidazol gel
0.75%
1
$0
Necessary actions,
restrictions, or limits
on use
PA, QL (90)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
124
Name of Drug
Tier level
What the drug will
cost you
metronidazol lot
0.75%
1
$0
mometasone cre
0.1%
1
$0
mometasone oin
0.1%
1
$0
mupirocin oin 2%
1
$0
nyamyc pow 100000
1
$0
nystat/triam cre
1
$0
nystat/triam oin
1
$0
nystatin cre 100000
1
$0
nystatin oin 100000
1
$0
nystatin pow 100000
1
$0
nystop pow 100000
1
$0
PANRETIN GEL 0.1% 2
$0
permethrin cre 5%
1
$0
PICATO GEL 0.015%
2
$0
PICATO GEL 0.05%
2
$0
podofilox sol 0.5%
1
$0
prednicarbat cre 0.1%
1
$0
prednicarbat oin 0.1%
1
$0
procto-pak cre 1%
1
$0
proctozone cre -hc
2.5%
1
$0
REGRANEX GEL
0.01%
2
$0
SANTYL OIN 250/GM
2
$0
Necessary actions,
restrictions, or limits
on use
PA
selenium sul lot 2.5% 1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
125
Name of Drug
Tier level
What the drug will
cost you
silver sulfa cre 1%
1
$0
SOLARAZE GEL 3%
W/W
2
$0
ssd cre 1%
1
$0
sulfacetamid sus 10%
1
$0
TAZORAC CRE
0.05%
2
$0
TAZORAC CRE 0.1%
2
$0
TAZORAC GEL
0.05%
2
$0
TAZORAC GEL 0.1%
2
$0
triamcinolon cre
0.025%
1
$0
triamcinolon cre 0.1%
1
$0
triamcinolon cre 0.5%
1
$0
triamcinolon lot
0.025%
1
$0
triamcinolon lot 0.1%
1
$0
triamcinolon oin
0.025%
1
$0
triamcinolon oin 0.1%
1
$0
triamcinolon oin 0.5%
1
$0
triderm cre 0.1%
1
$0
u-cort cre 1%
1
$0
VALCHLOR GEL
0.016%
2
$0
VOLTAREN GEL 1%
2
$0
Necessary actions,
restrictions, or limits
on use
QL (200)
Dermatological Agents (Drugs Affecting Skin)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
126
Name of Drug
Tier level
What the drug will
cost you
antifungal cre 2%
3
$0
athlete foot cre 1%
3
$0
bacitr zinc oin
500/gm
3
$0
bacitracin oin
500/gm
3
$0
castellani liq paint
3
$0
hydro skin lot 1%
3
$0
lamisil af aer 1%
3
$0
lice killing sha 0.334%
3
$0
lice treatme lot 1%
3
$0
lice trtmnt liq crm
rnse
3
$0
tolnaftate cre 1%
3
$0
tolnaftate pow 1%
3
$0
tolnaftate sol 1%
3
$0
zinc oxide oin 20%
3
$0
zinc oxide oin 20%
3
$0
Necessary actions,
restrictions, or limits
on use
Enzyme Replacement/ Modifiers
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ADAGEN INJ 250/ML
2
$0
LA
ALDURAZYME INJ
2.9MG/5M
2
$0
LA, PA
CEREZYME INJ
400UNIT
2
$0
LA, PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
127
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
CREON CAP
36000UNT
2
$0
CYSTADANE POW
2
$0
ELAPRASE INJ
6MG/3ML
2
$0
PA
FABRAZYME INJ
35MG
2
$0
LA, PA
KUVAN TAB 100MG
2
$0
LA
levocarnitin inj
200mg/ml
1
$0
levocarnitin sol
1gm/10ml
1
$0
levocarnitin tab
330mg
1
$0
LUMIZYME INJ
50MG
2
$0
NAGLAZYME INJ
1MG/ML
2
$0
ORFADIN CAP 10MG
2
$0
ORFADIN CAP 2MG
2
$0
ORFADIN CAP 5MG
2
$0
ZAVESCA CAP
100MG
2
$0
ZENPEP CAP
10000UNT
2
$0
ZENPEP CAP
15000UNT
2
$0
ZENPEP CAP
20000UNT
2
$0
ZENPEP CAP
25000UNT
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
128
Name of Drug
Tier level
What the drug will
cost you
ZENPEP CAP
3000UNIT
2
$0
ZENPEP CAP
5000UNIT
2
$0
Necessary actions,
restrictions, or limits
on use
Gastrointestinal Agents
Name of Drug
Tier level
What the drug will
cost you
atropine sul inj
0.05mg/1
1
$0
atropine sul inj
0.1mg/ml
1
$0
dicyclomine cap 10mg 1
$0
dicyclomine sol
10mg/5ml
1
$0
dicyclomine tab 20mg
1
$0
methscopolam tab
2.5mg
1
$0
diphen/atrop liq 2.5/5
1
$0
diphen/atrop tab
2.5mg
1
$0
FULYZAQ TAB
125MG
2
$0
loperamide cap 2mg
1
$0
metoclopram inj
5mg/ml
1
$0
metoclopram sol
5mg/5ml
1
$0
metoclopram tab 5mg
1
$0
RELISTOR INJ
12/0.6ML
2
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
129
Name of Drug
Tier level
What the drug will
cost you
RELISTOR INJ
12/0.6ML
2
$0
RELISTOR INJ
8/0.4ML
2
$0
ursodiol tab 250mg
1
$0
ursodiol tab 500mg
1
$0
famotidine inj
10mg/ml
1
$0
FAMOTIDINE INJ
20MG/50M
2
$0
famotidine tab 20mg
1
$0
famotidine tab 40mg
1
$0
ranitidine cap 150mg
1
$0
ranitidine cap 300mg
1
$0
ranitidine inj 150/6ml
1
$0
ranitidine syp
15mg/ml
1
$0
ranitidine tab 150mg
1
$0
ranitidine tab 300mg
1
$0
AMITIZA CAP
24MCG
2
$0
AMITIZA CAP 8MCG
2
$0
LOTRONEX TAB
0.5MG
2
$0
LOTRONEX TAB
1MG
2
$0
constulose sol
10gm/15
1
$0
enulose sol 10gm/15
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
130
Name of Drug
Tier level
What the drug will
cost you
generlac sol 10gm/15
1
$0
lactulose sol 10gm/15
1
$0
polyeth glyc pow 3350
nf
1
$0
PREPOPIK PAK
2
$0
CARAFATE SUS
1GM/10ML
2
$0
misoprostol tab
100mcg
1
$0
misoprostol tab
200mcg
1
$0
sucralfate tab 1gm
1
$0
DEXILANT CAP
30MG DR
2
$0
DEXILANT CAP
60MG DR
2
$0
ESOMEPRAZOLE
CAP 49.3MG
1
$0
omeprazole cap 10mg 1
$0
omeprazole cap 20mg 1
$0
omeprazole cap 40mg 1
$0
Necessary actions,
restrictions, or limits
on use
Gastrointestinal Agents (Bowel, Instestine, And Stomach Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
acid gone
3
$0
almacone dbl sus
strength
3
$0
alum hydrox sus
320/5ml
3
$0
sus
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
131
Name of Drug
Tier level
What the drug will
cost you
antacid
500mg
chw
3
$0
antacid
750mg
chw
3
$0
antacid
sus
3
$0
anti-diarrhe tab 2mg
3
$0
bisac-evac sup
10mg
3
$0
bisacodyl
ec
tab 5mg
3
$0
bismatrol
262mg
chw
3
$0
bismatrol
262/15ml
sus
3
$0
cal antacid chw
1000mg
3
$0
CITRUCEL
ORANGE
3
$0
3
$0
docusate cal cap
240mg
3
$0
fiber laxatv tab 625mg
3
$0
fiber therap pow
58.6%
3
$0
fiber therap tab
500mg
3
$0
FIBERCON
625MG
3
$0
3
$0
docqlace
100mg
Necessary actions,
restrictions, or limits
on use
POW
cap
TAB
foam antacid chw 8020mg
GAVISCON CHW
3
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
132
Name of Drug
Tier level
What the drug will
cost you
3
$0
GAVISCON
EX-STR
CHW
GAVISCON
SUS
3
$0
GAVISCON
SUS
3
$0
ene
3
$0
gnp milk mag sus
3
$0
KONSYL
100%
POW
3
$0
KONSYL
100%
POW
3
$0
3
$0
3
$0
3
$0
loperamide liq
1mg/5ml
3
$0
mi-acid
3
$0
3
$0
tab 8.6mg 3
$0
gnp enema
konsyl
pow 30.9%
KONSYL
71.67%
POW
KONSYL-D
52.3%
POW
chw
mintox plus chw
qc senna
reguloid
48.57%
Necessary actions,
restrictions, or limits
on use
pow
3
$0
sb bismuth tab
262mg
3
$0
sb fib lax pow 33%
3
$0
senna
8.8mg/5
syp
3
$0
sm fiber
pow 28.3% 3
$0
sodium bicar tab 10gr
3
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
133
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
soluble fib pow
therapy
3
$0
acid reducer tab
10mg
3
$0
famotidine tab 10mg
3
$0
diocto
liq
50mg/5ml
3
$0
doc-q-lax
50mg
3
$0
docusol mini ene
3
$0
dok
3
$0
enemeez plus ene 203
283
$0
gnp clearlax pow
3
$0
MIRALAX
3350 NF
3
$0
SM MINERAL OIL
3
$0
OMEPRAZOLE TAB
20MG
3
$0
omeprazole tab
20mg
3
$0
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
ENABLEX TAB 15MG
2
$0
ST
ENABLEX TAB
7.5MG
2
$0
ST
MYRBETRIQ TAB
25MG
2
$0
ST
tab 8.6-
tab 100mg
POW
Genitourinary Agents
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
134
Necessary actions,
restrictions, or limits
on use
ST
Name of Drug
Tier level
What the drug will
cost you
MYRBETRIQ TAB
50MG
2
$0
oxybutynin syp
5mg/5ml
1
$0
oxybutynin tab 10mg
er
1
$0
oxybutynin tab 15mg
er
1
$0
oxybutynin tab 5mg
1
$0
oxybutynin tab 5mg er
1
$0
tolterodine tab 1mg
1
$0
tolterodine tab 2mg
1
$0
VESICARE TAB
10MG
2
$0
VESICARE TAB 5MG
2
$0
AVODART CAP
0.5MG
2
$0
CIALIS TAB 2.5MG
2
$0
PA, QL (30)
CIALIS TAB 5MG
2
$0
PA, QL (30)
finasteride tab 5mg
1
$0
JALYN CAP
2
$0
RAPAFLO CAP 4MG
2
$0
RAPAFLO CAP 8MG
2
$0
tamsulosin cap 0.4mg
1
$0
CYSTAGON CAP
150MG
2
$0
CYSTAGON CAP
50MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
135
Name of Drug
Tier level
What the drug will
cost you
ELMIRON CAP
100MG
2
$0
neo/poly gu sol 40/ml
ir
1
$0
sodium chlor sol 0.9%
irr
1
$0
AURYXIA TAB
210MG
2
$0
calc acetate cap
667mg
1
$0
FOSRENOL CHW
1000MG
2
$0
FOSRENOL CHW
500MG
2
$0
FOSRENOL CHW
750MG
2
$0
RENVELA PAK
0.8GM
2
$0
RENVELA PAK
2.4GM
2
$0
RENVELA TAB
800MG
2
$0
clindamycin cre 2%
vag
1
$0
metronidazol gel
0.75%vag
1
$0
miconazole 3 sup
200mg
1
$0
PREMARIN VAG
CRE 0.625MG
2
$0
terconazole cre 0.4%
1
$0
terconazole sup 80mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
136
Name of Drug
Tier level
What the drug will
cost you
vandazole gel 0.75%
1
$0
zazole cre 0.4%
1
$0
zazole cre 0.8%
1
$0
Necessary actions,
restrictions, or limits
on use
Genitourinary Agents (Bladder, Genital, And Kidney Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
clotrimazole cre 1%
vag
3
$0
miconazole sup
100mg
3
$0
miconazole 7 cre 2%
3
$0
Necessary actions,
restrictions, or limits
on use
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Name of Drug
Tier level
What the drug will
cost you
budesonide cap
3mg/24hr
1
$0
dexameth pho inj
10mg/ml
1
$0
dexameth pho inj
120mg/30
1
$0
dexamethason elx
0.5/5ml
1
$0
dexamethason tab
0.5mg
1
$0
dexamethason tab
0.75mg
1
$0
dexamethason tab
1.5mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
137
Name of Drug
Tier level
What the drug will
cost you
dexamethason tab
1mg
1
$0
dexamethason tab
2mg
1
$0
dexamethason tab
4mg
1
$0
dexamethason tab
6mg
1
$0
fludrocort tab 0.1mg
1
$0
hydrocort tab 10mg
1
$0
hydrocort tab 5mg
1
$0
methylpr ace inj
40mg/ml
1
$0
methylpr ace inj
80mg/ml
1
$0
methylpr ss inj 125mg
1
$0
methylpr ss inj 40mg
1
$0
methylpred pak 4mg
1
$0
methylpred tab 16mg
1
$0
methylpred tab 32mg
1
$0
methylpred tab 4mg
1
$0
methylpred tab 8mg
1
$0
ORAPRED ODT TAB
10MG
2
$0
pred sod pho sol
5mg/5ml
1
$0
prednisolone sol
15mg/5ml
1
$0
prednisolone sol
25mg/5ml
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
138
Name of Drug
Tier level
What the drug will
cost you
prednisolone tab
10mg odt
2
$0
prednisolone tab
15mg odt
2
$0
prednisolone tab
30mg odt
2
$0
prednisone sol
5mg/5ml
1
$0
prednisone tab 10mg
1
$0
prednisone tab 1mg
1
$0
prednisone tab 2.5mg
1
$0
prednisone tab 20mg
1
$0
prednisone tab 50mg
1
$0
prednisone tab 5mg
1
$0
triamcin ace inj
10mg/ml
1
$0
triamcin ace inj
40mg/ml
1
$0
UCERIS TAB 9MG
2
$0
Necessary actions,
restrictions, or limits
on use
ST
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Name of Drug
Tier level
What the drug will
cost you
oxandrolone tab
10mg
1
$0
oxandrolone tab
2.5mg
1
$0
ANDRODERM DIS
2MG/24HR
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
139
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ANDRODERM DIS
4MG/24HR
2
$0
ANDROID CAP
10MG
2
$0
danazol cap 100mg
1
$0
danazol cap 200mg
1
$0
danazol cap 50mg
1
$0
testost cyp inj
200mg/ml
1
$0
testost enan inj
200mg/ml
1
$0
TESTRED CAP
10MG
2
$0
ELLA TAB 30MG
2
$0
lyza tab 0.35mg
1
$0
medroxypr ac inj
150mg/ml
1
$0
norethindron tab
0.35mg
1
$0
pirmella tab 1/35
1
$0
tri-previfem tab
1
$0
tri-sprintec tab
1
$0
trinessa tab
1
$0
vyfemla tab 0.4-35
1
$0
DELESTROGEN INJ
10MG/ML
2
$0
PA
estradiol tab 0.5mg
1
$0
PA
estradiol tab 1mg
1
$0
PA
estradiol tab 2mg
1
$0
PA
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
140
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
MENEST TAB 0.3MG
2
$0
PA
MENEST TAB
0.625MG
2
$0
PA
MENEST TAB
1.25MG
2
$0
PA
MENEST TAB 2.5MG
2
$0
PA
PREMARIN INJ
25MG
2
$0
PREMARIN TAB
0.3MG
2
$0
PA
PREMARIN TAB
0.45MG
2
$0
PA
PREMARIN TAB
0.625MG
2
$0
PA
PREMARIN TAB
0.9MG
2
$0
PA
PREMARIN TAB
1.25MG
2
$0
PA
PREMPHASE TAB
2
$0
PA
PREMPRO TAB .6252.5
2
$0
PA
PREMPRO TAB 0.31.5
2
$0
PA
PREMPRO TAB 0.451.5
2
$0
PA
PREMPRO TAB
0.625-5
2
$0
medroxypr ac tab
10mg
1
$0
medroxypr ac tab
2.5mg
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
141
Name of Drug
Tier level
What the drug will
cost you
medroxypr ac tab
5mg
1
$0
norethin ace tab 5mg
1
$0
raloxifene tab 60mg
1
$0
Necessary actions,
restrictions, or limits
on use
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
cabergoline tab 0.5mg 1
$0
chor gonadot inj
10000unt
1
$0
desmopressin inj
4mcg/ml
1
$0
desmopressin spr
0.01%
1
$0
desmopressin tab
0.1mg
1
$0
desmopressin tab
0.2mg
1
$0
HUMATROPE INJ
12MG
2
$0
PA
HUMATROPE INJ
24MG
2
$0
PA
INCRELEX INJ
40MG/4ML
2
$0
LA
NUTROPIN AQ INJ
20MG/2ML
2
$0
PA
NUTROPIN AQ INJ
NUSPIN 5
2
$0
PA
SAIZEN INJ 5MG
2
$0
PA
SAIZEN INJ 8.8MG
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
142
Name of Drug
Tier level
What the drug will
cost you
SAIZEN INJ 8.8MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
Name of Drug
Tier level
What the drug will
cost you
levothyroxin tab
100mcg
1
$0
levothyroxin tab
112mcg
1
$0
levothyroxin tab
125mcg
1
$0
levothyroxin tab
137mcg
1
$0
levothyroxin tab
150mcg
1
$0
levothyroxin tab
175mcg
1
$0
levothyroxin tab
200mcg
1
$0
levothyroxin tab
25mcg
1
$0
levothyroxin tab
300mcg
1
$0
levothyroxin tab
50mcg
1
$0
levothyroxin tab
75mcg
1
$0
levothyroxin tab
88mcg
1
$0
levoxyl tab 100mcg
1
$0
levoxyl tab 112mcg
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
143
Name of Drug
Tier level
What the drug will
cost you
levoxyl tab 125mcg
1
$0
levoxyl tab 137mcg
1
$0
levoxyl tab 150mcg
1
$0
levoxyl tab 175mcg
1
$0
levoxyl tab 200mcg
1
$0
levoxyl tab 25mcg
1
$0
levoxyl tab 50mcg
1
$0
levoxyl tab 75mcg
1
$0
levoxyl tab 88mcg
1
$0
liothyronine tab
25mcg
1
$0
liothyronine tab
50mcg
1
$0
liothyronine tab 5mcg
1
$0
SYNTHROID TAB
100MCG
2
$0
SYNTHROID TAB
112MCG
2
$0
SYNTHROID TAB
125MCG
2
$0
SYNTHROID TAB
137MCG
2
$0
SYNTHROID TAB
150MCG
2
$0
SYNTHROID TAB
175MCG
2
$0
SYNTHROID TAB
200MCG
2
$0
SYNTHROID TAB
25MCG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
144
Name of Drug
Tier level
What the drug will
cost you
SYNTHROID TAB
300MCG
2
$0
SYNTHROID TAB
50MCG
2
$0
SYNTHROID TAB
75MCG
2
$0
SYNTHROID TAB
88MCG
2
$0
unithroid tab 100mcg
1
$0
unithroid tab 112mcg
1
$0
unithroid tab 125mcg
1
$0
unithroid tab 150mcg
1
$0
unithroid tab 175mcg
1
$0
unithroid tab 200mcg
1
$0
unithroid tab 25mcg
1
$0
unithroid tab 300mcg
1
$0
unithroid tab 50mcg
1
$0
unithroid tab 75mcg
1
$0
unithroid tab 88mcg
1
$0
Necessary actions,
restrictions, or limits
on use
Hormonal Agents, Suppressant (Parathyroid)
Name of Drug
Tier level
What the drug will
cost you
SENSIPAR TAB
30MG
2
$0
SENSIPAR TAB
60MG
2
$0
SENSIPAR TAB
90MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
145
Hormonal Agents, Suppressant (Pituitary)
Name of Drug
Tier level
What the drug will
cost you
KORLYM TAB
300MG
2
$0
LUPR DEP-PED INJ
11.25MG
2
$0
LUPR DEP-PED INJ
15MG
2
$0
LUPRON DEPOT INJ
11.25MG
2
$0
octreotide inj
1000mcg
1
$0
octreotide inj 100mcg
1
$0
octreotide inj 200mcg
1
$0
octreotide inj 500mcg
1
$0
octreotide inj
50mcg/ml
1
$0
SANDOSTATIN KIT
LAR 10MG
2
$0
SANDOSTATIN KIT
LAR 20MG
2
$0
SANDOSTATIN KIT
LAR 30MG
2
$0
SIGNIFOR INJ
0.3MG/ML
2
$0
SIGNIFOR INJ
0.6MG/ML
2
$0
SIGNIFOR INJ
0.9MG/ML
2
$0
SOMATULINE INJ
120/.5ML
2
$0
Necessary actions,
restrictions, or limits
on use
LA, PA
SOMATULINE INJ
60/0.2ML
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
146
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
SOMATULINE INJ
90/0.3ML
2
$0
SOMAVERT INJ
10MG
2
$0
LA
SOMAVERT INJ
15MG
2
$0
LA
SOMAVERT INJ
20MG
2
$0
LA
SYNAREL SOL
2MG/ML
2
$0
Hormonal Agents, Suppressant (Thyroid)
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
methimazole tab
10mg
1
$0
methimazole tab 5mg
1
$0
propylthiour tab 50mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
ASTAGRAF XL CAP
0.5MG
2
$0
PA
ASTAGRAF XL CAP
1MG
2
$0
PA
ASTAGRAF XL CAP
5MG
2
$0
PA
azathioprine tab 50mg 1
$0
PA
Immunological Agents
BENLYSTA INJ
2
$0
PA
120MG
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
147
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
CELLCEPT IV INJ
500MG
2
$0
PA
cyclosporine cap
100mg
1
$0
PA
cyclosporine cap
100mg md
1
$0
PA
cyclosporine cap
25mg
1
$0
PA
cyclosporine cap
25mg mod
1
$0
PA
cyclosporine cap
50mg mod
1
$0
PA
cyclosporine inj
50mg/ml
1
$0
PA
cyclosporine sol
modified
1
$0
PA
ENBREL INJ
25/0.5ML
2
$0
ENBREL INJ 25MG
2
$0
ENBREL INJ
50MG/ML
2
$0
gengraf cap 100mg
1
$0
PA
gengraf cap 25mg
1
$0
PA
gengraf sol 100mg/ml
1
$0
PA
HUMIRA INJ
10MG/0.2
2
$0
HUMIRA KIT
20MG/0.4
2
$0
HUMIRA KIT
40MG/0.8
2
$0
HUMIRA PEN KIT
CROHNS
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
148
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
KINERET INJ
2
$0
mycophenolat cap
250mg
1
$0
PA
mycophenolat sus
200mg/ml
2
$0
PA
mycophenolat tab
500mg
1
$0
PA
mycophenolic tab
180mg dr
1
$0
PA
mycophenolic tab
360mg dr
1
$0
PA
NULOJIX INJ 250MG
2
$0
PA
PROGRAF INJ
5MG/ML
2
$0
PA
RAPAMUNE SOL
1MG/ML
2
$0
PA
REMICADE INJ
100MG
2
$0
PA
SANDIMMUNE CAP
100MG
2
$0
PA
SANDIMMUNE CAP
25MG
2
$0
PA
SANDIMMUNE SOL
100MG/ML
2
$0
PA
SIMULECT INJ 20MG
2
$0
PA
sirolimus tab 0.5mg
1
$0
PA
sirolimus tab 1mg
2
$0
PA
sirolimus tab 2mg
2
$0
PA
tacrolimus cap 0.5mg
1
$0
PA
tacrolimus cap 1mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
149
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
tacrolimus cap 5mg
1
$0
PA
TREXALL TAB 10MG
2
$0
PA
TREXALL TAB 15MG
2
$0
PA
TREXALL TAB 5MG
2
$0
PA
TREXALL TAB
7.5MG
2
$0
PA
ZORTRESS TAB
0.25MG
2
$0
PA
ZORTRESS TAB
0.5MG
2
$0
PA
ZORTRESS TAB
0.75MG
2
$0
PA
ATGAM INJ 250MG
2
$0
PA
BIVIGAM INJ 10%
2
$0
PA
CARIMUNE NF INJ
6GM
2
$0
PA
FLEBOGAMMA INJ
DIF 10%
2
$0
GAMASTAN S/D INJ
2
$0
PA
GAMMAGARD INJ
2.5GM/25
2
$0
PA
GAMMAKED INJ
1GM/10ML
2
$0
GAMMAPLEX INJ
10GM
2
$0
PA
GAMUNEX-C INJ
1GM/10ML
2
$0
PA
PRIVIGEN INJ
20GRAMS
2
$0
PA
SYNAGIS INJ 50MG
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
150
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
THYMOGLOBULN
INJ 25MG
2
$0
PA
ARCALYST INJ
220MG
2
$0
PA
ILARIS INJ 180MG
2
$0
leflunomide tab 10mg
1
$0
leflunomide tab 20mg
1
$0
ORENCIA INJ
125MG/ML
2
$0
ORENCIA INJ 250MG 2
$0
ACTHIB INJ
2
$0
ADACEL INJ
2
$0
BCG VACCINE INJ
2
$0
BOOSTRIX INJ
2
$0
BOOSTRIX INJ
2
$0
CERVARIX INJ
2
$0
COMVAX INJ
2
$0
DAPTACEL INJ
2
$0
DIP/TET PED INJ 255LFU
2
$0
ENGERIX-B INJ
10/0.5ML
2
$0
PA
ENGERIX-B INJ
10/0.5ML
2
$0
PA
ENGERIX-B INJ
20MCG/ML
2
$0
PA
GARDASIL 9 INJ
2
$0
GARDASIL 9 INJ
2
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
151
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
GARDASIL INJ
2
$0
GARDASIL INJ
2
$0
HAVRIX INJ
1440UNIT
2
$0
HAVRIX INJ 720UNIT
2
$0
IMOVAX RABIE INJ
2.5/ML
2
$0
INFANRIX INJ
2
$0
IPOL INJ INACTIVE
2
$0
IPOL INJ INACTIVE
2
$0
IXIARO INJ
2
$0
M-M-R II INJ LIVE
2
$0
MENACTRA INJ
2
$0
MENOMUNE INJ
A/C/Y/W
2
$0
MENVEO INJ
2
$0
PEDVAX HIB INJ
2
$0
PROQUAD INJ
2
$0
QUADRACEL INJ
2
$0
RABAVERT INJ
2
$0
PA
RECOMBIVA HB INJ
10MCG/ML
2
$0
PA
RECOMBIVA HB INJ
10MCG/ML
2
$0
PA
RECOMBIVA HB INJ
5MCG/0.5
2
$0
PA
RECOMBIVA-HB INJ
40MCG/ML
2
$0
PA
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
152
Name of Drug
Tier level
What the drug will
cost you
ROTARIX SUS
2
$0
ROTATEQ SOL
2
$0
TET/DIP TOX INJ 2-2
LF
2
$0
TETANUS TOX INJ
5LF ADS
2
$0
TRUMENBA INJ
2
$0
TWINRIX INJ
2
$0
TYPHIM VI INJ
2
$0
TYPHIM VI INJ
2
$0
VAQTA INJ 25/0.5ML
2
$0
VAQTA INJ 25/0.5ML
2
$0
VAQTA INJ
50UNT/ML
2
$0
VARIVAX INJ
2
$0
YF-VAX INJ
2
$0
ZOSTAVAX INJ
2
$0
Necessary actions,
restrictions, or limits
on use
PA
Inflammatory Bowel Disease Agents
Name of Drug
Tier level
What the drug will
cost you
APRISO CAP
0.375GM
2
$0
ASACOL HD TAB
800MG
2
$0
balsalazide cap
750mg
1
$0
DIPENTUM CAP
250MG
2
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
153
Name of Drug
Tier level
What the drug will
cost you
mesalamine kit 4gm
1
$0
sulfasalazin tab
500mg
1
$0
sulfazine ec tab
500mg
1
$0
Necessary actions,
restrictions, or limits
on use
Metabolic Bone Disease Agents
Name of Drug
Tier level
What the drug will
cost you
alendronate tab 10mg
1
$0
alendronate tab 35mg
1
$0
alendronate tab 40mg
1
$0
alendronate tab 5mg
1
$0
alendronate tab 70mg
1
$0
ATELVIA TAB
2
$0
calcitonin spr 200/act
1
$0
calcitriol cap 0.25mcg
1
$0
calcitriol cap 0.5mcg
1
$0
calcitriol inj 1mcg/ml
1
$0
calcitriol sol 1mcg/ml
1
$0
FORTEO SOL
600/2.4
2
$0
FOSAMAX + D TAB
70-2800
2
$0
FOSAMAX + D TAB
70-5600
2
$0
MIACALCIN INJ
200/ML
2
$0
Necessary actions,
restrictions, or limits
on use
PA
QL (4)
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
154
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
pamidronate inj
30/10ml
1
$0
pamidronate inj
6mg/ml
1
$0
pamidronate inj
90/10ml
1
$0
PARICALCITOL INJ
2MCG/ML
1
$0
PARICALCITOL INJ
5MCG/ML
2
$0
PROLIA SOL
60MG/ML
2
$0
RECLAST INJ
5/100ML
2
$0
XGEVA INJ
2
$0
ZEMPLAR CAP
1MCG
2
$0
PA
ZEMPLAR CAP
2MCG
2
$0
PA
zoledronic inj
4mg/5ml
1
$0
PA
ZOMETA INJ
4MG/100
2
$0
PA
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
EPIPEN 2-PAK INJ
0.3MG
2
$0
EPIPEN-JR INJ 2PAK
2
$0
PA
PA
Miscellaneous
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
155
Name of Drug
Tier level
What the drug will
cost you
FETZIMA CAP
TITRATIO
2
$0
FIRAZYR INJ
30MG/3ML
2
$0
lactated rin sol irrigat
1
$0
physiolyte sol
1
$0
physiosol sol irrigat
1
$0
ringers irr sol
1
$0
Name of Drug
Tier level
What the drug will
cost you
latanoprost sol
0.005%
1
$0
LUMIGAN SOL
0.01%
2
$0
TRAVATAN Z DRO
0.004%
2
$0
atropine sul sol 1% op
2
$0
naphazoline sol 0.1%
op
1
$0
RESTASIS EMU
0.05%
2
$0
bacit/polymy oin op
1
$0
bacitracin oin op
1
$0
ciprofloxacn sol 0.3%
op
1
$0
erythromycin oin op
1
$0
gentak oin 0.3% op
1
$0
Necessary actions,
restrictions, or limits
on use
Ophthalmic Agents
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
156
Name of Drug
Tier level
What the drug will
cost you
gentamicin sol 0.3%
op
1
$0
MOXEZA SOL 0.5%
2
$0
neo/bac/poly oin op
1
$0
neo/poly/gra sol op
1
$0
ofloxacin dro 0.3% op
1
$0
polymyxin b/ sol
trimethp
1
$0
sod sulfacet sol 10%
op
1
$0
tobramycin sol 0.3%
op
1
$0
trifluridine sol 1% op
1
$0
VIGAMOX DRO 0.5%
2
$0
ZIRGAN GEL 0.15%
2
$0
azelastine dro 0.05%
1
$0
cromolyn sod sol 4%
op
1
$0
PATADAY SOL 0.2%
2
$0
PATANOL SOL 0.1%
OP
2
$0
dexameth pho sol
0.1% op
1
$0
diclofenac sol 0.1%
op
1
$0
DUREZOL EMU
0.05%
2
$0
flurbiprofen sol 0.03%
op
1
$0
ketorolac sol 0.4%
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
157
Name of Drug
Tier level
What the drug will
cost you
ketorolac sol 0.5%
1
$0
neo/poly/bac oin /hc
1%op
1
$0
neo/poly/dex oin 0.1%
op
1
$0
neo/poly/dex sus
0.1% op
1
$0
neo/poly/hc sus op
1
$0
NEVANAC SUS 0.1%
2
$0
pred sod pho sol 1%
op
1
$0
prednisolone sus 1%
op
1
$0
sulf/pred na sol op
1
$0
tobra/dexame sus
0.3-0.1%
1
$0
ALPHAGAN P SOL
0.1%
2
$0
apraclonidin sol 0.5%
op
1
$0
AZOPT SUS 1% OP
2
$0
betaxolol sol 0.5% op
1
$0
brimonidine sol 0.15%
1
$0
brimonidine sol 0.2%
op
1
$0
carteolol sol 1% op
1
$0
COMBIGAN SOL
0.2/0.5%
2
$0
dorzol/timol sol 20.5%op
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
158
Name of Drug
Tier level
What the drug will
cost you
dorzolamide sol 2%
op
1
$0
levobunolol sol 0.5%
op
1
$0
metipranolol sol 0.3%
oph
1
$0
PHOSPHOLINE SOL
0.125%OP
2
$0
timolol gel sol 0.25%
op
1
$0
timolol gel sol 0.5%
op
1
$0
timolol mal sol 0.25%
op
1
$0
timolol mal sol 0.5%
op
1
$0
BIMATOPROST SOL
0.03%
2
$0
Necessary actions,
restrictions, or limits
on use
Ophthalmic Agents (Eye Drugs)
Name of Drug
Tier level
What the drug will
cost you
akwa tears oin op
3
$0
artifi tears sol op
3
$0
artificial sol tears
3
$0
GENTEAL
OPTH
DRO
3
$0
GENTEAL
GEL
3
$0
GENTEAL
0.3%
GEL
3
$0
3
$0
liquitears sol
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
159
Name of Drug
Tier level
What the drug will
cost you
MURO 128
OP
OIN 5%
3
$0
MURO 128
2% OP
SOL
3
$0
MURO 128
5% OP
SOL
3
$0
natural bal sol 0.4%
3
$0
REFRESH
OP
3
$0
REFRESH CELL
DRO 1% OP
3
$0
REFRESH PLUS
DRO 0.5% OP
3
$0
REFRESH TEAR
DRO 0.5% OP
3
$0
sod chloride oin 5%
op
3
$0
sod chloride sol 5%
op
3
$0
SYSTANE PF SOL
3
$0
Name of Drug
Tier level
What the drug will
cost you
acetic acid sol 2% otic
1
$0
CIPRODEX SUS 0.30.1%
2
$0
fluocin acet oil 0.01%
1
$0
neo/poly/hc sol 1%
otic
1
$0
Necessary actions,
restrictions, or limits
on use
DRO
Otic Agents
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
160
Name of Drug
Tier level
What the drug will
cost you
neo/poly/hc sus 1%
otic
1
$0
ofloxacin dro 0.3%otic
1
$0
Necessary actions,
restrictions, or limits
on use
Respiratory Tract Agents
Name of Drug
Tier level
What the drug will
cost you
FLOVENT DISK AER
100MCG
2
$0
FLOVENT DISK AER
250MCG
2
$0
FLOVENT DISK AER
50MCG
2
$0
FLOVENT HFA AER
110MCG
2
$0
FLOVENT HFA AER
220MCG
2
$0
FLOVENT HFA AER
44MCG
2
$0
QVAR AER 40MCG
2
$0
QVAR AER 80MCG
2
$0
cetirizine syp 1mg/ml
1
$0
cyproheptad tab 4mg
1
$0
desloratadin tab 2.5
odt
1
$0
desloratadin tab 5mg
1
$0
diphenhydram inj
50mg/ml
1
$0
stavudine sol 1mg/ml
1
$0
montelukast chw 4mg
1
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
161
Name of Drug
Tier level
What the drug will
cost you
montelukast chw 5mg
1
$0
montelukast gra 4mg
1
$0
montelukast tab 10mg
1
$0
zafirlukast tab 10mg
1
$0
zafirlukast tab 20mg
1
$0
ZYFLO CR TAB
600MG
2
$0
ZYFLO TAB 600MG
2
$0
ATROVENT HFA
AER 17MCG
2
$0
ipratropium sol
0.02%inh
1
$0
SPIRIVA CAP
HANDIHLR
2
$0
SPIRIVA SPR
RESPIMAT
2
$0
aminophyllin inj
25mg/ml
1
$0
theophylline tab
100mg cr
1
$0
theophylline tab
200mg cr
1
$0
theophylline tab
300mg er
1
$0
theophylline tab
450mg er
1
$0
theophylline tab
600mg er
1
$0
ADVAIR DISKU AER
100/50
2
$0
Necessary actions,
restrictions, or limits
on use
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
162
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
ADVAIR DISKU AER
250/50
2
$0
ADVAIR DISKU AER
500/50
2
$0
ADVAIR HFA AER
115/21
2
$0
ADVAIR HFA AER
230/21
2
$0
ADVAIR HFA AER
45/21
2
$0
albuterol neb 0.083%
1
$0
PA
albuterol neb 0.5%
1
$0
PA
albuterol neb
0.63mg/3
1
$0
PA
albuterol neb
1.25mg/3
1
$0
PA
albuterol syp 2mg/5ml
1
$0
albuterol tab 2mg
1
$0
albuterol tab 4mg
1
$0
albuterol tab 4mg er
1
$0
albuterol tab 8mg er
1
$0
ANORO ELLIPT AER
62.5-25
2
$0
BREO ELLIPTA INH
100-25
2
$0
COMBIVENT AER
RESPIMAT
2
$0
ipratropium/ sol
albuter
1
$0
PROAIR HFA AER
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
163
Name of Drug
Tier level
What the drug will
cost you
SEREVENT DIS AER
50MCG
2
$0
SYMBICORT AER
160-4.5
2
$0
SYMBICORT AER
80-4.5
2
$0
terbutaline inj 1mg/ml
1
$0
VENTOLIN HFA AER
2
$0
CROMOLYN SOD
NEB 20MG/2ML
1
$0
ayr
spr 0.65%
3
$0
azelastine spr 0.1%
1
$0
azelastine spr 0.15%
1
$0
cromolyn sod spr
5.2/act
3
$0
DRISTAN
0.05%
3
$0
flunisolide spr 0.025%
1
$0
fluticasone spr 50mcg
1
$0
ipratropium spr 0.03%
1
$0
ipratropium spr 0.06%
1
$0
nasal saline spr
0.65%
3
$0
TYZINE PED DRO
0.05%
2
$0
LETAIRIS TAB 10MG
2
$0
LETAIRIS TAB 5MG
2
$0
OPSUMIT TAB 10MG
2
$0
REVATIO INJ
2
$0
Necessary actions,
restrictions, or limits
on use
PA
SPR
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
164
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
sildenafil tab 20mg
1
$0
PA
TRACLEER TAB
125MG
2
$0
LA
TRACLEER TAB
62.5MG
2
$0
LA
VENTAVIS SOL
10MCG/ML
2
$0
PA
VENTAVIS SOL
20MCG/ML
2
$0
PA
DALIRESP TAB
500MCG
2
$0
ESBRIET CAP
267MG
2
$0
PA
KALYDECO PAK
50MG
2
$0
PA
KALYDECO PAK
75MG
2
$0
PA
KALYDECO TAB
150MG
2
$0
PA
PROLASTIN-C INJ
1000MG
2
$0
PA
PULMOZYME SOL
1MG/ML
2
$0
PA
XOLAIR SOL 150MG
2
$0
LA
Respiratory Tract Agents (Allergies, Cough, Cold, And Lung Condition Drugs)
Name of Drug
Tier level
What the drug will
cost you
aller-chlor tab 4mg
3
$0
allergy
cap 25mg
3
$0
allergy
tab 25mg
3
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
165
Name of Drug
Tier level
What the drug will
cost you
banophen
12.5/5ml
3
$0
cetirizine tab 5mg
3
$0
fexofenadine tab
60mg
3
$0
gnp all day tab
allergy
3
$0
loratadine syp
5mg/5ml
3
$0
loratadine tab 10mg
3
$0
mapap
500mg
3
$0
night time tab 25mg
3
$0
alavert alrg tab /sinus
3
$0
allergy-d
120mg
3
$0
allergy/cong tab relief
3
$0
ALLFEN
400MG
TAB
3
$0
aprodine
60mg
tab 2.53
$0
benzonatate cap
100mg
3
$0
benzonatate cap
200mg
3
$0
chest congst tab rlf pe
3
$0
child silfed liq
15mg/5ml
3
$0
cld head cng tab
nighttim
3
$0
Necessary actions,
restrictions, or limits
on use
liq
cap
tab 5-
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
166
Name of Drug
Tier level
What the drug will
cost you
cold/allergy elx
children
3
$0
cold/allergy tab 410mg
3
$0
cold/cough elx child
3
$0
CONGESTAC
60-400MG
TAB
3
$0
CONGESTAC
60-400MG
TAB
3
$0
3
$0
cough & cold tab
3
$0
coughtab
200mg
tab
3
$0
dimetapp
nighttim
liq
3
$0
DIMETAPP CLD ELX
/ALLERGY
3
$0
endacof-dm liq 2.51-5
3
$0
extra action syp 10010/5
3
$0
guaifenesin tab
600mg er
3
$0
liq cgh/cold 3
$0
cough
100/5ml
kidkare
Necessary actions,
restrictions, or limits
on use
syp
mucinex nasl spr
0.05%
3
$0
mucus relief liq
100/5ml
3
$0
mucus relief liq 5100mg
3
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
167
Name of Drug
Tier level
What the drug will
cost you
mucus relief tab
400mg
3
$0
mucus relief tab dm
3
$0
NASAL DECONG LIQ
30MG/5ML
3
$0
nasal decong tab
10mg
3
$0
nasal decong tab
30mg
3
$0
PHENYLHIST LIQ
DH
3
$0
ROBITUSSIN LIQ
CGH/COLD
3
$0
robitussin liq
cgh/cong
3
$0
sudogest
60mg
3
$0
3
$0
3
$0
tussin cf
tussin dm
Necessary actions,
restrictions, or limits
on use
tab 4liq
liq max
Skeletal Muscle Relaxants
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
baclofen tab 10mg
1
$0
baclofen tab 20mg
1
$0
cyclobenzapr tab
10mg
1
$0
PA
cyclobenzapr tab 5mg
1
$0
PA
methocarbam tab
500mg
1
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
168
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
methocarbam tab
750mg
1
$0
PA
orphenadrine inj
30mg/ml
1
$0
PA
orphenadrine tab
100mg er
1
$0
PA
tizanidine tab 2mg
1
$0
tizanidine tab 4mg
1
$0
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
BUTISOL SOD TAB
30MG
2
$0
PA
SECONAL CAP
100MG
2
$0
PA
estazolam tab 1mg
1
$0
QL (60)
estazolam tab 2mg
1
$0
QL (30)
flurazepam cap 15mg
1
$0
QL (60)
flurazepam cap 30mg
1
$0
QL (30)
temazepam cap 15mg 1
$0
QL (30)
temazepam cap
22.5mg
1
$0
QL (30)
temazepam cap 30mg 1
$0
QL (30)
temazepam cap
7.5mg
1
$0
QL (120)
triazolam tab 0.125mg 1
$0
QL (30)
triazolam tab 0.25mg
1
$0
QL (60)
ROZEREM TAB 8MG
2
$0
Sleep Disorder Agents
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
169
Necessary actions,
restrictions, or limits
on use
PA
Name of Drug
Tier level
What the drug will
cost you
zaleplon cap 10mg
1
$0
zaleplon cap 5mg
1
$0
zolpidem tab 10mg
1
$0
PA
zolpidem tab 5mg
1
$0
PA
modafinil tab 100mg
1
$0
PA
modafinil tab 200mg
1
$0
PA
XYREM SOL
500MG/ML
2
$0
LA
Necessary actions,
restrictions, or limits
on use
Therapeutic Nutrients/ Minerals/ Electrolytes
Name of Drug
Tier level
What the drug will
cost you
EXJADE TAB 125MG
2
$0
EXJADE TAB 250MG
2
$0
EXJADE TAB 500MG
2
$0
kionex pow
1
$0
SAMSCA TAB 15MG
2
$0
PA
SAMSCA TAB 30MG
2
$0
PA
sod poly sul sus
15gm/60
1
$0
CARBAGLU TAB
200MG
2
$0
D10W/NACL INJ
0.2%
2
$0
d2.5w/nacl inj 0.45%
1
$0
d5w/lr inj
1
$0
d5w/nacl inj 0.2%
1
$0
d5w/nacl inj 0.33%
1
$0
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
170
Name of Drug
Tier level
What the drug will
cost you
d5w/nacl inj 0.45%
1
$0
d5w/nacl inj 0.9%
1
$0
ISOLYTE-P INJ /D5W
2
$0
ISOLYTE-S INJ
2
$0
kcl in nacl inj
1
$0
kcl/d5w inj 0.15%
1
$0
kcl/d5w inj 0.3%
1
$0
kcl/d5w/lr inj 0.15%
1
$0
kcl/d5w/nacl inj
.075/.45
1
$0
kcl/d5w/nacl inj
.15/.33%
1
$0
kcl/d5w/nacl inj
.15/.45%
1
$0
kcl/d5w/nacl inj
.22/.45
1
$0
kcl/d5w/nacl inj
0.15/0.2
1
$0
kcl/d5w/nacl inj
0.15/0.2
1
$0
kcl/d5w/nacl inj
0.3/0.45
1
$0
KCL/NACL INJ 0.150.9
1
$0
klor-con 10 tab
10meq er
1
$0
klor-con 8 tab 8meq
er
1
$0
klor-con m20 tab
20meq er
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
171
Name of Drug
Tier level
What the drug will
cost you
lactated rin inj
1
$0
magnesium su inj
50%
1
$0
magnesium su inj
50%
1
$0
normosol -m inj /d5w
1
$0
NORMOSOL -R INJ
/D5W
2
$0
NORMOSOL-R INJ
PH 7.4
2
$0
ped elctrlyt sol fruit
3
$0
PLASMA-LYTE INJ 148
2
$0
PLASMA-LYTE INJ
56/D5W
2
$0
pot chloride cap
10meq er
1
$0
pot chloride cap 8meq
er
1
$0
POT CHLORIDE INJ
10MEQ
2
$0
pot chloride inj 20meq
1
$0
pot chloride inj
2meq/ml
1
$0
POT CHLORIDE INJ
40MEQ
2
$0
pot chloride liq 10%
2
$0
pot chloride liq 20%
2
$0
pot chloride tab 8meq
er
1
$0
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
172
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
pot citrate tab
1080mg
1
$0
pot citrate tab
1620mg
2
$0
pot citrate tab 540mg
er
1
$0
pot cl micro tab
10meq er
1
$0
pot cl micro tab
20meq er
1
$0
ringers inj
1
$0
sod chloride inj 0.45%
1
$0
sod chloride inj 0.9%
1
$0
sod chloride inj 2.5/ml
1
$0
sod chloride inj 3%
1
$0
sod chloride inj 5%
1
$0
SOD LACTATE INJ
5MEQ/ML
2
$0
tpn electrol inj
1
$0
AMINOSYN 7% INJ
/LYTES
2
$0
PA
AMINOSYN II INJ
10%
2
$0
PA
AMINOSYN II INJ 7%
2
$0
PA
AMINOSYN II INJ
8.5%
2
$0
PA
aminosyn ii inj 8.5/lyte
1
$0
PA
aminosyn inj 8.5/lyte
1
$0
PA
AMINOSYN M INJ
3.5%
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
173
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
AMINOSYN-HBC INJ
7%
2
$0
PA
AMINOSYN-PF INJ
10%
2
$0
PA
AMINOSYN-PF INJ
7%
2
$0
PA
AMINOSYN-RF INJ
5.2%
2
$0
PA
CLINIMIX E INJ
2.75/D10
2
$0
PA
CLINIMIX E INJ
2.75/D5W
2
$0
PA
CLINIMIX E INJ
4.25/D10
2
$0
PA
CLINIMIX E INJ
4.25/D25
2
$0
PA
CLINIMIX E INJ
4.25/D5W
2
$0
PA
CLINIMIX E INJ
5%/D15W
2
$0
PA
CLINIMIX E INJ
5%/D20W
2
$0
PA
CLINIMIX E INJ
5%/D25W
2
$0
PA
CLINIMIX INJ
2.75/D5W
2
$0
PA
CLINIMIX INJ
4.25/D10
2
$0
PA
CLINIMIX INJ
4.25/D20
2
$0
PA
CLINIMIX INJ
4.25/D25
2
$0
PA
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
174
Necessary actions,
restrictions, or limits
on use
Name of Drug
Tier level
What the drug will
cost you
CLINIMIX INJ
4.25/D5W
2
$0
PA
CLINIMIX INJ
5%/D15W
2
$0
PA
CLINIMIX INJ
5%/D20W
2
$0
PA
CLINIMIX INJ
5%/D25W
2
$0
PA
dextrose inj 10%
1
$0
PA
dextrose inj 5%
1
$0
PA
FREAMINE HBC INJ
6.9%
2
$0
PA
hepatamine sol 8%
1
$0
PA
intralipid inj 20%
1
$0
PA
NEPHRAMINE INJ
5.4%
2
$0
PA
premasol sol 6%
1
$0
PA
PROCALAMINE INJ
3%
2
$0
PA
PROSOL INJ 20%
2
$0
PA
TRAVASOL INJ 10%
2
$0
PA
PRENATAL VITAMIN
TABLET
2
$0
SODIUM FLUORIDE
2.2 MG
2
$0
Therapeutic Nutrients/ Minerals/ Electrolytes (Multivitamins And Replacement Solutions)
Name of Drug
Tier level
What the drug will
cost you
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
175
Name of Drug
Tier level
What the drug will
cost you
mag oxide
420mg
3
$0
calcitrate tab
3
$0
calcitrate tab 950mg
3
$0
calcium
500mg
chw
3
$0
calcium
tab vit d
3
$0
calcium carb sus
1250/5ml
3
$0
calcium carb tab
1250mg
3
$0
calcium carb tab
600mg
3
$0
CALCIUM GLUC TAB
500MG
3
$0
calcium/d
400
3
$0
oys shell ca tab /vit d
3
$0
oyster shell tab
500mg
3
$0
animal shape chw
3
$0
animal shape chw +
iron
3
$0
AQUADEKS
3
$0
3
$0
b-complex w/ tab b-12
3
$0
balanc b-100 tab
100mg
3
$0
biotin
3
$0
Necessary actions,
restrictions, or limits
on use
tab
tab 600-
aquadeks
CAP
dro
tab 300mcg
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
176
Name of Drug
Tier level
What the drug will
cost you
CALCIUM CARB TAB
648MG
3
$0
centamin
3
$0
3
$0
3
$0
certavite/ tab
antioxid
3
$0
cyanocobalam inj
1000mcg
3
$0
cyanocobalam inj
1000mcg
3
$0
DRISDOL
8000/ML
3
$0
3
$0
ELDERTONIC ELX
3
$0
ergocalcifer sol
8000/ml
3
$0
ferrex 150 cap
150mg
3
$0
FERROUS GLUC
TAB 324MG
3
$0
ferrous sulf tab
325mg fc
3
$0
folic acid tab 1mg
3
$0
folic acid tab
400mcg
3
$0
3
$0
3
$0
3
$0
liq
CENTRUM
CHW
CERTAVITE
SENIOR
TAB
ecee plus
DRO
tab
FOSFREE
geravim
mag oxide
400mg
Necessary actions,
restrictions, or limits
on use
TAB
liq
tab
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
177
Name of Drug
Tier level
What the drug will
cost you
mag-delay
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
multi-delyn liq
3
$0
MULTI-DELYN LIQ
/IRON
3
$0
niacin
tr
3
$0
niacinamide tab
500mg
3
$0
once daily tab
3
$0
once daily tab iron
3
$0
oysco 500+d tab
3
$0
oyst shell/d tab
500mg
3
$0
POLY-VI-SOL DRO
3
$0
POLY-VI-SOL DRO
/IRON
3
$0
poly-vita
3
$0
3
$0
tab
MAGNEBIND
300
TAB
magnesium
250mg
tab
magnesium
500mg
tab
magonate
500mg
tab
MEPHYTON
5MG
meribin
Necessary actions,
restrictions, or limits
on use
TAB
cap 5mg
tab 500mg
dro
PRENATAL
TAB
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
178
Tier level
What the drug will
cost you
3
$0
3
$0
3
$0
sm vit b-1 tab 100mg 3
$0
stress form/ tab zinc
3
$0
STRESS-600/ TAB
ZINC
3
$0
THERA BETA- TAB
CAROTENE
3
$0
thiamine hcl inj
100mg/ml
3
$0
total b/c
3
$0
TRI-VI-SOL DRO
/IRON
3
$0
TRI-VI-SOL SOL
3
$0
tri-vita
3
$0
vitamin a cap
10000unt
3
$0
vitamin b-1 tab
100mg
3
$0
vitamin b-1 tab 50mg
3
$0
vitamin b-6 tab
100mg
3
$0
vitamin b-6 tab 50mg
3
$0
vitamin c
250mg
chw
3
$0
vitamin c
500mg
chw
3
$0
Name of Drug
PRENATAL
27-0.8MG
Necessary actions,
restrictions, or limits
on use
TAB
pyridoxine inj
100mg/ml
SLOW-MAG
TAB
tab
sol
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
179
Name of Drug
Tier level
What the drug will
cost you
vitamin c
tab 250mg
3
$0
vitamin c
tab 500mg
3
$0
3
$0
Name of Drug
Tier level
What the drug will
cost you
BEXSERO INJ
2
$0
desmopressin sol
0.01%
1
$0
TENIVAC INJ 5-2LF
2
$0
ZYPREXA RELP INJ
210MG
2
$0
VITAMIN K1 INJ
10MG/ML
Necessary actions,
restrictions, or limits
on use
Uncategorized
Necessary actions,
restrictions, or limits
on use
PA= Prior authorization required; QL= Quantity limit, dispense limit for 30 days, unless
otherwise noted; ST= Step therapy exception required; *= Medicaid covered medications; LA=
Limited access; GC= Gap Coverage; MO= Mail Order;
180
8
8-mop cap 10mg .................................... 120
A
abacav/lamiv tab /zidovud ........................ 73
abacavir tab 300mg ................................. 73
abelcet inj 5mg/ml .................................... 43
abilify disc tab 10mg ................................ 67
abilify disc tab 15mg ................................ 67
abilify inj 9.75mg ...................................... 67
abilify main inj 300mg............................... 67
abilify main inj 400mg............................... 67
abilify tab 10mg ........................................ 67
abilify tab 15mg ........................................ 67
abilify tab 20mg ........................................ 68
abilify tab 2mg .......................................... 68
abilify tab 30mg ........................................ 68
abilify tab 5mg .......................................... 68
abraxane inj 100mg ................................. 49
abreva
cre 10% ................................ 120
acampro cal tab 333mg.............................. 8
acarbose tab 100mg ................................ 82
acarbose tab 25mg .................................. 82
acarbose tab 50mg .................................. 82
acebutolol cap 200mg ............................ 103
acebutolol cap 400mg ............................ 103
acephen
sup 120mg............................ 12
acephen
sup 325mg............................ 12
acephen
sup 650mg............................ 12
acetamin sol 160/5ml ........................... 13
acetazolamid cap 500mg er ................... 109
acetazolamid tab 125mg ........................ 109
acetazolamid tab 250mg ........................ 110
acetic acid sol 2% otic ............................ 160
acid gone sus ...................................... 131
acid reducer tab 10mg ........................... 134
acitretin cap 10mg .................................. 120
acitretin cap 17.5mg ............................... 120
acitretin cap 25mg .................................. 120
acne medicat gel 10% ............................ 120
acne medicat gel 5% .............................. 120
acne medicat lot 10% ............................. 120
acne medicat lot 5% ............................... 120
acthib inj................................................. 151
actimmune inj 2mu/0.5 ............................. 50
actoplus met tab xr ................................... 82
acyclovir cap 200mg ................................ 78
acyclovir na inj 50mg/ml ........................... 78
acyclovir sus 200/5ml ...............................78
acyclovir tab 400mg .................................78
acyclovir tab 800mg .................................78
adacel inj ................................................151
adagen inj 250/ml ...................................127
adefov dipiv tab 10mg ..............................77
adrucil inj 500/10ml ..................................50
advair disku aer 100/50 ..........................162
advair disku aer 250/50 ..........................163
advair disku aer 500/50 ..........................163
advair hfa aer 115/21 .............................163
advair hfa aer 230/21 .............................163
advair hfa aer 45/21 ...............................163
advicor tab 1000-20................................112
advicor tab 1000-40................................112
advicor tab 500-20mg.............................112
advicor tab 750-20mg.............................112
afeditab tab 30mg cr...............................106
afeditab tab 60mg cr...............................106
afinitor dis tab 2mg ...................................50
afinitor dis tab 3mg ...................................50
afinitor dis tab 5mg ...................................50
afinitor tab 10mg ......................................50
afinitor tab 2.5mg .....................................50
afinitor tab 5mg ........................................50
afinitor tab 7.5mg .....................................50
aggrenox cap 25-200mg ..........................92
akwa tears oin op .................................159
ala cort cre 1% .......................................120
alavert alrg tab /sinus .............................166
albenza tab 200mg ...................................61
albuterol neb 0.083% .............................163
albuterol neb 0.5% .................................163
albuterol neb 0.63mg/3...........................163
albuterol neb 1.25mg/3...........................163
albuterol syp 2mg/5ml ............................163
albuterol tab 2mg ...................................163
albuterol tab 4mg ...................................163
albuterol tab 4mg er ...............................163
albuterol tab 8mg er ...............................163
aldurazyme inj 2.9mg/5m .......................127
alendronate tab 10mg ............................154
alendronate tab 35mg ............................154
alendronate tab 40mg ............................154
alendronate tab 5mg ..............................154
alendronate tab 70mg ............................154
alimta inj 500mg .......................................49
alinia sus 100/5ml ....................................61
alinia tab 500mg .......................................61
all day allg sol 5mg/5ml ............................ 43
aller-chlor syp 2mg/5ml ........................... 43
aller-chlor tab 4mg ................................ 165
allergy
cap 25mg ............................... 165
allergy
tab 25mg ............................... 165
allergy/cong tab relief ............................. 166
allergy-d tab 5-120mg ......................... 166
allfen
tab 400mg .............................. 166
allopurinol tab 100mg ............................... 45
allopurinol tab 300mg ............................... 45
almacone dbl sus strength ..................... 131
alphagan p sol 0.1% .............................. 158
alprazolam con 1 mg/ml ........................... 79
alprazolam tab 0.25 odt............................ 79
alprazolam tab 0.25mg............................. 79
alprazolam tab 0.5mg............................... 79
alprazolam tab 0.5mg er .......................... 80
alprazolam tab 0.5mg od.......................... 80
alprazolam tab 1mg ................................. 80
alprazolam tab 1mg er ............................. 80
alprazolam tab 1mg odt............................ 80
alprazolam tab 2mg ................................. 80
alprazolam tab 2mg er ............................. 80
alprazolam tab 2mg odt............................ 80
alprazolam tab 3mg er ............................. 80
altoprev tab 20mg er .............................. 112
altoprev tab 40mg er .............................. 112
altoprev tab 60mg er .............................. 113
alum hydrox sus 320/5ml ...................... 131
amantadine cap 100mg............................ 62
amantadine syp 50mg/5ml ....................... 62
amantadine tab 100mg ............................ 62
ambisome inj 50mg .................................. 43
amcinonide cre 0.1%.............................. 120
amcinonide lot 0.1% ............................... 120
amcinonide oin 0.1% .............................. 120
amifostine inj 500mg ................................ 50
amilor/hctz tab 5-50 ................................. 97
amiloride tab 5mg .................................. 110
aminophyllin inj 25mg/ml ........................ 162
aminosyn 7% inj /lytes............................ 173
aminosyn ii inj 10% ................................ 173
aminosyn ii inj 7% .................................. 173
aminosyn ii inj 8.5% ............................... 173
aminosyn ii inj 8.5/lyte ............................ 173
aminosyn inj 8.5/lyte .............................. 173
aminosyn m inj 3.5% .............................. 173
aminosyn-hbc inj 7% .............................. 174
aminosyn-pf inj 10% ............................... 174
aminosyn-pf inj 7% ................................. 174
aminosyn-rf inj 5.2%............................... 174
amiodarone inj 50mg/ml ...........................96
amiodarone tab 200mg ............................96
amiodarone tab 400mg ............................96
amitiza cap 24mcg .................................130
amitiza cap 8mcg ...................................130
amitriptylin tab 100mg ..............................39
amitriptylin tab 10mg ................................39
amitriptylin tab 150mg ..............................39
amitriptylin tab 25mg ................................39
amitriptylin tab 50mg ................................39
amitriptylin tab 75mg ................................40
amlod/benazp cap 10-20mg .....................97
amlod/benazp cap 10-40mg .....................97
amlod/benazp cap 2.5-10mg ....................97
amlod/benazp cap 5-10mg .......................97
amlod/benazp cap 5-20mg .......................97
amlod/benazp cap 5-40mg .......................98
amlod/valsar tab /hctz ..............................98
amlod/valsar tab 10-160mg ......................98
amlod/valsar tab 10-320mg ......................98
amlod/valsar tab 5-160mg ........................98
amlod/valsar tab 5-320mg ........................98
amlodipine tab 10mg ..............................106
amlodipine tab 2.5mg .............................106
amlodipine tab 5mg ................................106
ammonium lac lot 12% ...........................120
amnesteem cap 10mg ............................120
amnesteem cap 20mg ............................121
amnesteem cap 40mg ............................121
amox/k clav chw 200mg ...........................18
amox/k clav chw 400mg ...........................18
amox/k clav sus 200/5ml ..........................18
amox/k clav sus 400/5ml ..........................18
amox/k clav sus 600/5ml ..........................18
amox/k clav tab 250mg ............................19
amox/k clav tab 500mg ............................19
amox/k clav tab 875mg ............................19
amoxapine tab 100mg ..............................40
amoxapine tab 150mg ..............................40
amoxapine tab 25mg ................................40
amoxapine tab 50mg ................................40
amoxicillin cap 250mg ..............................19
amoxicillin cap 500mg ..............................19
amoxicillin chw 125mg .............................19
amoxicillin chw 250mg .............................19
amoxicillin sus 125/5ml ............................19
amoxicillin sus 200/5ml ............................19
amoxicillin sus 250/5ml ............................19
amoxicillin sus 400/5ml ............................19
amoxicillin tab 500mg ...............................19
amoxicillin tab 875mg ...............................19
amphetamine tab 10mg ......................... 116
amphetamine tab 12.5mg ...................... 116
amphetamine tab 15mg ......................... 116
amphetamine tab 20mg ......................... 116
amphetamine tab 30mg ......................... 116
amphetamine tab 5mg ........................... 116
amphetamine tab 7.5mg ........................ 116
amphotericin inj 50mg .............................. 43
ampicillin cap 250mg................................ 19
ampicillin cap 500mg................................ 19
ampicillin inj 10gm.................................... 19
ampicillin inj 125mg .................................. 19
ampicillin inj 1gm...................................... 20
ampicillin sus 125/5ml .............................. 20
ampicillin sus 250/5ml .............................. 20
amp-sulbacta inj 1.5gm ............................ 19
amp-sulbacta inj 15gm ............................. 19
ampyra tab 10mg ................................... 119
anagrelide cap 0.5mg............................... 92
anastrozole tab 1mg ................................ 61
androderm dis 2mg/24hr ........................ 139
androderm dis 4mg/24hr ........................ 140
android cap 10mg .................................. 140
animal shape chw .................................. 176
animal shape chw + iron ........................ 176
anoro ellipt aer 62.5-25 .......................... 163
antacid
chw 500mg ........................... 132
antacid
chw 750mg ........................... 132
antacid
sus ........................................ 132
anti-diarrhe tab 2mg ............................... 132
antifungal cre 2% ................................. 127
apap
tab 500mg ............................... 13
apap/codeine sol 120-12/5 ......................... 4
apap/codeine tab 300-15mg....................... 4
apap/codeine tab 300-30mg....................... 4
apap/codeine tab 300-60mg....................... 4
apidra inj solostar ..................................... 87
apidra inj u-100 ........................................ 87
aplenzin tab 174mg .................................. 34
aplenzin tab 348mg .................................. 34
aplenzin tab 522mg .................................. 34
apokyn inj 10mg/ml .................................. 62
apraclonidin sol 0.5% op ........................ 158
apriso cap 0.375gm ............................... 153
aprodine tab 2.5-60mg ....................... 166
aptiom tab 200mg .................................... 30
aptiom tab 400mg .................................... 30
aptiom tab 600mg .................................... 30
aptiom tab 800mg .................................... 30
aptivus cap 250mg ................................... 75
aptivus sol ................................................ 75
aquadeks cap .....................................176
aquadeks dro .....................................176
arcalyst inj 220mg ..................................151
arranon inj 5mg/ml ...................................50
arthrts pain tab 650mg .............................13
artifi tears sol op .....................................159
artificial sol tears ..................................159
arzerra con 100/5ml .................................50
asacol hd tab 800mg ..............................153
ascomp/cod cap 30mg .............................. 5
aspir-81 tab 81mg ec............................13
aspirin
sup 300mg ...............................13
aspirin
sup 600mg ...............................13
aspirin
tab 325mg ................................13
astagraf xl cap 0.5mg .............................147
astagraf xl cap 1mg ................................147
astagraf xl cap 5mg ................................147
atacand tab 16mg ....................................93
atacand tab 32mg ....................................93
atelvia tab...............................................154
atenol/chlor tab 100-25mg ........................98
atenol/chlor tab 50-25mg ..........................98
atenolol tab 100mg .................................103
atenolol tab 25mg ...................................103
atenolol tab 50mg ...................................103
atgam inj 250mg.....................................150
athlete foot cre 1% .................................127
atorvastatin tab 10mg .............................113
atorvastatin tab 20mg .............................113
atorvastatin tab 40mg .............................113
atorvastatin tab 80mg .............................113
atovaq/progu tab 250-100 ........................61
atovaquone sus 750/5ml ..........................61
atripla tab .................................................72
atropine sul inj 0.05mg/1 ........................129
atropine sul inj 0.1mg/ml ........................129
atropine sul sol 1% op ............................156
atrovent hfa aer 17mcg ..........................162
aubagio tab 14mg ..................................119
aubagio tab 7mg ....................................119
aug betamet lot 0.05% ...........................121
auryxia tab 210mg ..................................136
avandamet tab 2-1000mg ........................82
avandamet tab 2-500mg ..........................82
avandamet tab 4-500mg ..........................82
avandaryl tab 4-1mg.................................82
avandaryl tab 4-2mg.................................82
avandaryl tab 8-4mg.................................82
avandia tab 2mg.......................................82
avandia tab 4mg.......................................82
avandia tab 8mg.......................................82
avastin inj ................................................. 48
avodart cap 0.5mg ................................. 135
ayr
spr 0.65% ................................ 164
azacitidine inj 100mg................................ 49
azactam/dex inj 1gm ................................ 18
azactam/dex inj 2gm ................................ 18
azasan tab 100mg ................................... 50
azasan tab 75 mg .................................... 50
azathioprine tab 50mg............................ 147
azelastine dro 0.05%.............................. 157
azelastine spr 0.1% ................................ 164
azelastine spr 0.15% .............................. 164
azilect tab 0.5mg ...................................... 64
azilect tab 1mg ......................................... 64
azithromycin inj 500mg ............................ 20
azithromycin pow 1gm pak ....................... 20
azithromycin sus 100/5ml ......................... 21
azithromycin sus 200/5ml ......................... 21
azithromycin tab 250mg ........................... 21
azithromycin tab 500mg ........................... 21
azithromycin tab 600mg ........................... 21
azopt sus 1% op .................................... 158
azor tab 10-20mg ..................................... 98
azor tab 10-40mg ..................................... 98
azor tab 5-20mg ....................................... 98
azor tab 5-40mg ....................................... 98
aztreonam inj 1gm ................................... 18
B
baciim inj 50000unt .................................. 14
bacit/polymy oin op ................................ 156
bacitr zinc oin 500/gm ........................... 127
bacitracin oin 500/gm ........................... 127
bacitracin oin op ..................................... 156
baclofen tab 10mg ................................. 168
baclofen tab 20mg ................................. 168
balanc b-100 tab 100mg ........................ 176
balsalazide cap 750mg .......................... 153
banophen liq 12.5/5ml ........................ 166
banzel sus 40mg/ml ................................. 30
banzel tab 200mg .................................... 30
banzel tab 400mg .................................... 30
baraclude sol .05mg/ml ............................ 77
bcg vaccine inj ....................................... 151
b-complex w/ tab b-12 ............................ 176
beleodaq inj 500mg .................................. 50
benazep/hctz tab 10-12.5 ......................... 98
benazep/hctz tab 20-12.5 ......................... 98
benazep/hctz tab 20-25mg ....................... 98
benazep/hctz tab 5-6.25........................... 99
benazepril tab 10mg ................................ 94
benazepril tab 20mg .................................94
benazepril tab 40mg .................................94
benazepril tab 5mg ...................................94
benicar hct tab 20-12.5.............................99
benicar hct tab 40-12.5.............................99
benicar hct tab 40-25mg ...........................99
benicar tab 20mg .....................................93
benicar tab 40mg .....................................94
benicar tab 5mg .......................................94
benlysta inj 120mg .................................147
benzonatate cap 100mg ........................166
benzonatate cap 200mg ........................166
benztropine inj 1mg/ml .............................62
benztropine tab 0.5mg..............................62
benztropine tab 1mg.................................62
benztropine tab 2mg.................................62
betameth dip cre 0.05% .........................121
betameth dip oin 0.05%..........................121
betameth val cre 0.1%............................121
betameth val lot 0.1% .............................121
betameth val oin 0.1% ............................121
betaseron inj 0.3mg ................................119
betaxolol sol 0.5% op .............................158
betaxolol tab 10mg .................................103
betaxolol tab 20mg .................................103
bexsero inj..............................................180
bicalutamide tab 50mg .............................50
bicillin l-a inj 600000 .................................20
bicnu inj 100mg ........................................50
bimatoprost sol 0.03% ............................159
biotin
tab 300mcg .............................176
bisac-evac sup 10mg ...........................132
bisacodyl tab 5mg ec...........................132
bismatrol chw 262mg ..........................132
bismatrol sus 262/15ml .......................132
bisoprl/hctz tab 10/6.25 ............................99
bisoprl/hctz tab 2.5/6.25 ...........................99
bisoprl/hctz tab 5-6.25mg .........................99
bisoprol fum tab 10mg ............................104
bisoprol fum tab 5mg ..............................104
bivigam inj 10% ......................................150
bleomycin inj 30unit ..................................50
boostrix inj ..............................................151
bosulif tab 100mg .....................................50
bosulif tab 500mg .....................................51
breo ellipta inh 100-25 ............................163
brilinta tab 90mg.......................................92
brimonidine sol 0.15% ............................158
brimonidine sol 0.2% op .........................158
brintellix tab 10mg ....................................34
brintellix tab 20mg ....................................34
brintellix tab 5mg ...................................... 34
brisdelle cap 7.5mg .................................. 36
bromocriptin cap 5mg............................... 62
bromocriptin tab 2.5mg ............................ 62
budesonide cap 3mg/24hr ...................... 137
bumetanide inj 0.25/ml ........................... 110
bumetanide tab 0.5mg ........................... 110
bumetanide tab 1mg .............................. 110
bumetanide tab 2mg .............................. 110
bupren/nalox sub 2-0.5mg ......................... 8
bupren/nalox sub 8-2mg ............................ 8
buprenorphin inj 0.3mg/ml .......................... 8
buprenorphin sub 2mg ............................... 8
buprenorphin sub 8mg ............................... 8
buproban tab 150mg ................................ 34
bupropion tab 100mg ............................... 34
bupropion tab 100mg sr ........................... 34
bupropion tab 150mg sr ........................... 34
bupropion tab 200mg sr ........................... 34
bupropion tab 75mg ................................. 34
bupropn hcl tab 150mg xl ......................... 34
bupropn hcl tab 300mg xl ......................... 34
buspirone tab 10mg ................................. 78
buspirone tab 15mg ................................. 78
buspirone tab 30mg ................................. 78
buspirone tab 5mg ................................... 79
buspirone tab 7.5mg ................................ 79
busulfex inj 6mg/ml .................................. 51
but/apap/caf cap codeine ........................... 5
butisol sod tab 30mg .............................. 169
butrans dis 15mcg/hr.................................. 1
byetta inj 10mcg ....................................... 82
byetta inj 5mcg ......................................... 82
C
cabergoline tab 0.5mg............................ 142
cal antacid chw 1000mg ........................ 132
calc acetate cap 667mg ......................... 136
calcipotrien sol 0.005% .......................... 121
calcitonin spr 200/act ............................. 154
calcitrate tab ........................................ 176
calcitrate tab 950mg ............................. 176
calcitriol cap 0.25mcg............................. 154
calcitriol cap 0.5mcg............................... 154
calcitriol inj 1mcg/ml ............................... 154
calcitriol sol 1mcg/ml .............................. 154
calcium
chw 500mg........................... 176
calcium
tab vit d ................................ 176
calcium carb sus 1250/5ml ..................... 176
calcium carb tab 1250mg ....................... 176
calcium carb tab 600mg ......................... 176
calcium carb tab 648mg .........................177
calcium gluc tab 500mg ..........................176
calcium/d tab 600-400 .........................176
cancidas inj 50mg ....................................43
cancidas inj 70mg ....................................43
candesa/hctz tab 16-12.5 .........................99
candesa/hctz tab 32-12.5 .........................99
candesa/hctz tab 32-25mg .......................99
candesartan tab 16mg..............................94
candesartan tab 32mg..............................94
candesartan tab 4mg................................94
candesartan tab 8mg................................94
capastat sul inj 1gm..................................47
caprelsa tab 100mg ..................................51
caprelsa tab 300mg ..................................51
captopr/hctz tab 25-15mg .........................99
captopr/hctz tab 25-25mg .........................99
captopr/hctz tab 50-15mg .........................99
captopr/hctz tab 50-25mg .........................99
captopril tab 100mg ..................................94
captopril tab 12.5mg .................................95
captopril tab 25mg ....................................95
captopril tab 50mg ....................................95
carac cre 0.5% .........................................51
carafate sus 1gm/10ml ...........................131
carb/levo er tab 25-100mg........................64
carb/levo er tab 50-200mg........................64
carb/levo tab 10-100mg ............................64
carb/levo tab 25-100mg ............................64
carb/levo tab 25-250mg ............................64
carbaglu tab 200mg................................170
carbamazepin cap 100mg er ....................81
carbamazepin cap 200mg er ....................30
carbamazepin cap 300mg er ....................30
carbamazepin chw 100mg........................81
carbamazepin sus 100/5ml.......................30
carbamazepin tab 200mg .........................30
carbamazepin tab 200mg er .....................30
carbamazepin tab 400mg er .....................30
carboplatin inj 150/15ml ...........................51
carimune nf inj 6gm ................................150
carteolol sol 1% op .................................158
cartia xt cap 120/24hr .............................106
cartia xt cap 180/24hr .............................106
cartia xt cap 240/24hr .............................106
cartia xt cap 300/24hr .............................106
carvedilol tab 12.5mg .............................104
carvedilol tab 25mg ................................104
carvedilol tab 3.125mg ...........................104
carvedilol tab 6.25mg .............................104
castellani liq paint .................................127
cayston inh 75mg ..................................... 18
cdp/amitrip tab 10-25mg .......................... 40
cdp/amitrip tab 5-12.5mg ......................... 40
cefaclor cap 250mg .................................. 16
cefaclor cap 500mg .................................. 16
cefaclor er tab 500mg .............................. 16
cefazolin inj 10gm .................................... 16
cefazolin inj 1gm ...................................... 16
cefazolin inj 1gm/50ml.............................. 16
cefazolin inj 500mg .................................. 16
cefdinir cap 300mg ................................... 16
cefdinir sus 125/5ml ................................. 16
cefdinir sus 250/5ml ................................. 16
cefepime inj 1gm ...................................... 16
cefepime inj 2gm ...................................... 16
cefoxitin inj 10gm ..................................... 16
cefoxitin inj 1gm ....................................... 16
cefoxitin inj 2gm ....................................... 16
cefpodo prox sus 100/5ml ........................ 16
cefpodo prox sus 50mg/5ml ..................... 16
cefpodoxime tab 100mg ........................... 17
cefpodoxime tab 200mg ........................... 17
cefprozil sus 125/5ml ............................... 17
cefprozil sus 250/5ml ............................... 17
cefprozil tab 250mg .................................. 17
cefprozil tab 500mg .................................. 17
ceftriaxone inj 10gm ................................. 17
ceftriaxone inj 1gm ................................... 17
ceftriaxone inj 250mg ............................... 17
ceftriaxone inj 2gm ................................... 17
ceftriaxone inj 500mg ............................... 17
cefuroxime inj 1.5gm ................................ 17
cefuroxime inj 7.5gm ................................ 17
cefuroxime inj 750mg ............................... 17
cefuroxime tab 250mg.............................. 17
celecoxib cap 100mg ............................... 10
celecoxib cap 200mg ............................... 10
celecoxib cap 400mg ............................... 10
celecoxib cap 50mg ................................. 10
cellcept iv inj 500mg ............................... 148
celontin cap 300mg .................................. 25
centamin liq ........................................ 177
centrum
chw...................................... 177
cephalexin cap 250mg ............................. 17
cephalexin cap 500mg ............................. 17
cephalexin sus 125/5ml............................ 17
cephalexin sus 250/5ml............................ 17
cephalexin tab 250mg .............................. 17
cephalexin tab 500mg .............................. 17
cerebyx inj 500/10ml ................................ 30
cerezyme inj 400unit .............................. 127
certavite tab senior ..............................177
certavite/ tab antioxid ...........................177
cervarix inj ..............................................151
cetirizine tab 5mg .................................166
cetirizine syp 1mg/ml ..............................161
chantix pak 0.5& 1mg ................................ 9
chantix pak 1mg ........................................ 9
chantix tab 0.5mg ...................................... 9
chantix tab 1mg ......................................... 9
chest congst tab rlf pe ............................166
child asa chw 81mg ...............................13
child silfed liq 15mg/5ml .........................166
chloramphen inj 1gm ................................14
chlordiazep cap 10mg ..............................80
chlordiazep cap 25mg ..............................80
chlordiazep cap 5mg ................................80
chlorhex glu sol 0.12% ...........................119
chloroquine tab 250mg .............................61
chloroquine tab 500mg .............................61
chlorothiaz tab 250mg ............................111
chlorothiaz tab 500mg ............................111
chlorpromaz inj 25mg/ml ..........................64
chlorpromaz tab 100mg ............................64
chlorpromaz tab 10mg..............................64
chlorpromaz tab 200mg ............................65
chlorpromaz tab 25mg..............................65
chlorpromaz tab 50mg..............................65
chlorpropam tab 100mg ...........................82
chlorpropam tab 250mg ...........................82
chlorthalid tab 25mg ...............................111
chlorthalid tab 50mg ...............................111
cholestyram pow 4gm lite .......................114
chor gonadot inj 10000unt ......................142
cialis tab 2.5mg ......................................135
cialis tab 5mg .........................................135
ciclopirox cre 0.77% ...............................121
ciclopirox gel 0.77% ...............................121
ciclopirox sol 8% ....................................121
ciclopirox sus 0.77%...............................121
cilostazol tab 100mg.................................92
cilostazol tab 50mg ..................................92
ciprodex sus 0.3-0.1% ............................160
ciprofloxacn inj 200mg..............................21
ciprofloxacn inj 400mg..............................21
ciprofloxacn sol 0.3% op ........................156
ciprofloxacn sus 250mg/5 .........................21
ciprofloxacn sus 500mg/5 .........................21
ciprofloxacn tab 1000mg ..........................21
ciprofloxacn tab 100mg ............................22
ciprofloxacn tab 250mg ............................22
ciprofloxacn tab 500mg ............................22
ciprofloxacn tab 500mg er ........................ 22
ciprofloxacn tab 750mg ............................ 22
cisplatin inj 100mg ................................... 51
citalopram sol 10mg/5ml .......................... 36
citalopram tab 10mg ................................ 36
citalopram tab 20mg ................................ 36
citalopram tab 40mg ................................ 36
citrucel pow orange ............................ 132
cladribine inj 1mg/ml ................................ 51
claravis cap 10mg .................................. 121
claravis cap 20mg .................................. 121
claravis cap 30mg .................................. 121
claravis cap 40mg .................................. 121
clarithromyc tab 250mg ............................ 21
clarithromyc tab 500mg ............................ 21
cld head cng tab nighttim ....................... 166
clindacin kit pac 1% ............................... 121
clindamy/ben gel 1-5% ........................... 121
clindamycin cap 150mg............................ 14
clindamycin cap 300mg............................ 14
clindamycin cap 75mg.............................. 14
clindamycin cre 2% vag ......................... 136
clindamycin gel 1% ................................ 121
clindamycin inj 150mg/ml ......................... 14
clindamycin inj 300mg .............................. 15
clindamycin inj 600mg .............................. 15
clindamycin inj 900mg .............................. 15
clindamycin lot 1% ................................. 121
clindamycin pad 1% ............................... 122
clindamycin sol 1% ................................ 122
clindamycin sol 75mg/5ml ........................ 15
clinimix e inj 2.75/d10 ............................. 174
clinimix e inj 2.75/d5w ............................ 174
clinimix e inj 4.25/d10 ............................. 174
clinimix e inj 4.25/d25 ............................. 174
clinimix e inj 4.25/d5w ............................ 174
clinimix e inj 5%/d15w ............................ 174
clinimix e inj 5%/d20w ............................ 174
clinimix e inj 5%/d25w ............................ 174
clinimix inj 2.75/d5w ............................... 174
clinimix inj 4.25/d10 ................................ 174
clinimix inj 4.25/d20 ................................ 174
clinimix inj 4.25/d25 ................................ 174
clinimix inj 4.25/d5w ............................... 175
clinimix inj 5%/d15w ............................... 175
clinimix inj 5%/d20w ............................... 175
clinimix inj 5%/d25w ............................... 175
clobetasol e cre 0.05% ........................... 122
clobetasol gel 0.05% .............................. 122
clobetasol oin 0.05% .............................. 122
clobetasol sol 0.05% .............................. 122
clolar inj 1mg/ml .......................................51
clomipramine cap 25mg ...........................40
clomipramine cap 50mg ...........................40
clomipramine cap 75mg ...........................40
clonazep odt tab 0.125mg ........................25
clonazep odt tab 0.25mg ..........................25
clonazep odt tab 0.5mg ............................25
clonazep odt tab 1mg ...............................25
clonazep odt tab 2mg ...............................25
clonazepam tab 0.5mg .............................25
clonazepam tab 1mg ................................25
clonazepam tab 2mg ................................25
clonidine tab 0.1mg ..................................93
clonidine tab 0.2mg ..................................93
clonidine tab 0.3mg ..................................93
clopidogrel tab 300mg ..............................92
clopidogrel tab 75mg ................................92
cloraz dipot tab 15mg ...............................80
cloraz dipot tab 3.75mg ............................80
cloraz dipot tab 7.5mg ..............................80
clotrim/beta cre diprop ............................122
clotrim/beta lot diprop .............................122
clotrimazole cre 1% ................................122
clotrimazole cre 1% vag .........................137
clotrimazole sol 1% ................................122
clotrimazole tro 10mg ...............................44
clozapine tab 100/odt ...............................71
clozapine tab 100mg ................................71
clozapine tab 12.5/odt ..............................71
clozapine tab 200mg ................................71
clozapine tab 25mg ..................................71
clozapine tab 25mg odt ............................71
clozapine tab 50mg ..................................71
coartem tab 20-120mg .............................61
colchicine cap 0.6mg ................................45
colchicine tab 0.6mg.................................45
cold/allergy elx children ..........................167
cold/allergy tab 4-10mg ..........................167
cold/cough elx child ..............................167
colestipol gra 5gm ..................................114
colestipol tab 1gm ..................................114
colistimeth inj 150mg ................................15
combigan sol 0.2/0.5% ...........................158
combivent aer respimat ..........................163
cometriq kit 100mg ...................................51
cometriq kit 140mg ...................................51
cometriq kit 60mg .....................................51
complera tab ............................................72
compro sup 25mg ....................................65
comvax inj ..............................................151
condylox gel 0.5% ..................................122
congestac tab 60-400mg ..................... 167
constulose sol 10gm/15 ......................... 130
copaxone inj 40mg/ml ............................ 119
copaxone kit 20mg/ml ............................ 119
cormax scalp sol 0.05% ......................... 122
cosmegen inj 0.5mg ................................. 51
cough
syp 100/5ml .......................... 167
cough & cold tab .................................... 167
coughtab tab 200mg .......................... 167
creon cap 36000unt ............................... 128
crestor tab 10mg .................................... 113
crestor tab 20mg .................................... 113
crestor tab 40mg .................................... 113
crestor tab 5mg ...................................... 113
crixivan cap 200mg .................................. 75
crixivan cap 400mg .................................. 75
cromolyn sod neb 20mg/2ml .................. 164
cromolyn sod sol 4% op ......................... 157
cromolyn sod spr 5.2/act ........................ 164
cubicin sol 500mg .................................... 15
cyanocobalam inj 1000mcg .................... 177
cyclobenzapr tab 10mg .......................... 168
cyclobenzapr tab 5mg ............................ 168
cyclophosph cap 25mg ............................ 48
cyclophosph cap 50mg ............................ 48
cycloset tab 0.8mg ................................... 82
cyclosporine cap 100mg ........................ 148
cyclosporine cap 100mg md................... 148
cyclosporine cap 25mg .......................... 148
cyclosporine cap 25mg mod................... 148
cyclosporine cap 50mg mod................... 148
cyclosporine inj 50mg/ml ........................ 148
cyclosporine sol modified ....................... 148
cyproheptad tab 4mg ............................. 161
cystadane pow ....................................... 128
cystagon cap 150mg .............................. 135
cystagon cap 50mg ................................ 135
cytarabine inj 100mg/ml ........................... 51
cytarabine inj 20mg/ml ............................. 51
D
d10w/nacl inj 0.2% ................................. 170
d2.5w/nacl inj 0.45% .............................. 170
d5w/lr inj................................................. 170
d5w/nacl inj 0.2% ................................... 170
d5w/nacl inj 0.33% ................................. 170
d5w/nacl inj 0.45% ................................. 171
d5w/nacl inj 0.9% ................................... 171
dacarbazine inj 200mg ............................. 51
dacogen inj 50mg..................................... 49
daliresp tab 500mcg ............................... 165
danazol cap 100mg ................................140
danazol cap 200mg ................................140
danazol cap 50mg ..................................140
dapsone tab 100mg..................................46
dapsone tab 25mg ...................................47
daptacel inj .............................................151
daraprim tab 25mg ...................................61
daunorubicin inj 5mg/ml ...........................51
daunoxome inj 2mg/ml .............................51
decitabine inj 50mg ..................................49
delestrogen inj 10mg/ml .........................140
demser cap 250mg ................................110
depen titra tab 250mg ..............................48
depo-provera inj 400/ml............................52
desipramine tab 100mg ............................40
desipramine tab 10mg ..............................40
desipramine tab 150mg ............................40
desipramine tab 25mg ..............................40
desipramine tab 50mg ..............................40
desipramine tab 75mg ..............................40
desloratadin tab 2.5 odt ..........................161
desloratadin tab 5mg ..............................161
desloratadin tab 5mg odt ..........................73
desmopressin inj 4mcg/ml ......................142
desmopressin sol 0.01% ........................180
desmopressin spr 0.01% ........................142
desmopressin tab 0.1mg ........................142
desmopressin tab 0.2mg ........................142
desonide cre 0.05%................................122
desonide lot 0.05% .................................122
desonide oin 0.05% ................................122
desoximetas cre 0.05% ..........................122
desoximetas cre 0.25% ..........................122
desoximetas gel 0.05% ..........................122
desoximetas oin 0.25% ..........................122
desvenlafax tab 100mg er ........................36
desvenlafax tab 50mg er ..........................36
dexameth pho inj 10mg/ml .....................137
dexameth pho inj 120mg/30 ...................137
dexameth pho sol 0.1% op .....................157
dexamethason elx 0.5/5ml......................137
dexamethason tab 0.5mg .......................137
dexamethason tab 0.75mg .....................137
dexamethason tab 1.5mg .......................137
dexamethason tab 1mg ..........................138
dexamethason tab 2mg ..........................138
dexamethason tab 4mg ..........................138
dexamethason tab 6mg ..........................138
dexilant cap 30mg dr ..............................131
dexilant cap 60mg dr ..............................131
dexrazoxane inj 250mg ............................52
dextroamphet cap 10mg er .................... 117
dextroamphet cap 15mg er .................... 117
dextroamphet cap 5mg er ...................... 117
dextroamphet tab 10mg ......................... 117
dextroamphet tab 5mg ........................... 117
dextrose inj 10% .................................... 175
dextrose inj 5% ...................................... 175
diazepam con 5mg/ml .............................. 80
diazepam gel 10mg .................................. 25
diazepam gel 2.5mg ................................. 25
diazepam gel 20mg .................................. 25
diazepam sol 1mg/ml ............................... 80
diazepam tab 10mg ................................. 80
diazepam tab 2mg ................................... 80
diazepam tab 5mg ................................... 80
diclofen pot tab 50mg ............................... 10
diclofenac gel 3% ................................... 122
diclofenac sol 0.1% op ........................... 157
diclofenac tab 100mg er ........................... 10
diclofenac tab 25mg dr ............................. 10
diclofenac tab 50mg dr ............................. 10
diclofenac tab 75mg dr ............................. 10
dicloxacill cap 250mg ............................... 20
dicloxacill cap 500mg ............................... 20
dicyclomine cap 10mg............................ 129
dicyclomine sol 10mg/5ml ...................... 129
dicyclomine tab 20mg ............................ 129
didanosine cap 125mg ............................. 73
didanosine cap 200mg ............................. 73
didanosine cap 250mg ............................. 73
didanosine cap 400mg ............................. 73
dificid tab 200mg ...................................... 21
diflorasone cre 0.05% ............................ 122
diflorasone oin 0.05%............................. 123
diflunisal tab 500mg ................................. 10
digitek tab 0.125mg ................................ 109
digitek tab 0.25mg .................................. 109
digoxin inj 0.25mg/1 ............................... 109
digoxin sol 50mcg/ml.............................. 109
digoxin tab 0.125mg ............................... 109
digoxin tab 0.25mg ................................. 109
dihydroergot inj 1mg/ml ............................ 46
dilantin cap 30mg ..................................... 30
diltiazem cap 120mg er .......................... 106
diltiazem cap 180mg/24 ......................... 106
diltiazem cap 240mg cd ......................... 106
diltiazem cap 300mg er .......................... 106
diltiazem cap 360mg/24 ......................... 106
diltiazem cap 420mg/24 ......................... 106
diltiazem cap 60mg er ............................ 107
diltiazem cap 90mg er ............................ 107
diltiazem inj 100mg ................................107
diltiazem inj 50/10ml ...............................107
diltiazem tab 120mg ...............................107
diltiazem tab 30mg .................................107
diltiazem tab 60mg .................................107
diltiazem tab 90mg .................................107
dilt-xr cap 120mg ....................................106
dilt-xr cap 180mg ....................................106
dilt-xr cap 240mg ....................................106
dimetapp liq nighttim ..........................167
dimetapp cld elx /allergy .........................167
diocto
liq 50mg/5ml ..........................134
dip/tet ped inj 25-5lfu ..............................151
dipentum cap 250mg ..............................153
diphen/atrop liq 2.5/5 ..............................129
diphen/atrop tab 2.5mg ..........................129
diphenhydram inj 50mg/ml .....................161
dipyridamole tab 25mg .............................92
dipyridamole tab 50mg .............................92
dipyridamole tab 75mg .............................92
disopyramide cap 100mg .........................96
disopyramide cap 150mg .........................96
disulfiram tab 250mg ................................. 8
disulfiram tab 500mg ................................. 8
divalproex cap 125mg ..............................45
divalproex tab 125mg dr ...........................45
divalproex tab 250mg dr ...........................26
divalproex tab 250mg er ...........................26
divalproex tab 500mg dr ...........................26
divalproex tab 500mg er ...........................26
docefrez inj 20mg .....................................52
docetaxel inj 80mg/4ml.............................52
docetaxel inj 80mg/8ml.............................52
docqlace cap 100mg ..........................132
doc-q-lax tab 8.6-50mg .......................134
docusate cal cap 240mg ........................132
docusol mini ene ....................................134
dok
tab 100mg...............................134
donepezil tab 10mg ..................................32
donepezil tab 10mg odt ............................32
donepezil tab 5mg ....................................32
donepezil tab 5mg odt ..............................32
donepezil tab hcl 23mg ............................32
dorzol/timol sol 2-0.5%op .......................158
dorzolamide sol 2% op ...........................159
doxazosin tab 1mg ...................................93
doxazosin tab 2mg ...................................93
doxazosin tab 4mg ...................................93
doxazosin tab 8mg ...................................93
doxepin hcl cap 100mg ............................40
doxepin hcl cap 10mg ..............................40
doxepin hcl cap 150mg ............................ 40
doxepin hcl cap 25mg .............................. 40
doxepin hcl cap 50mg .............................. 41
doxepin hcl cap 75mg .............................. 41
doxepin hcl con 10mg/ml ......................... 41
doxil inj 2mg/ml ........................................ 52
doxorubicin inj 50mg ................................ 52
doxy 100 inj 100mg .................................. 23
doxycyc mono tab 50mg .......................... 23
doxycyc mono tab 75mg .......................... 23
doxycycl hyc cap 100mg .......................... 23
doxycycl hyc cap 50mg ............................ 23
doxycycl hyc inj 100mg ............................ 23
doxycycl hyc tab 100mg ........................... 23
doxycycline sus 25mg/5ml ....................... 23
doxycycline tab 20mg............................... 23
driminate tab 50mg ............................... 43
drisdol
dro 8000/ml............................ 177
dristan
spr 0.05% .............................. 164
dronabinol cap 10mg................................ 42
dronabinol cap 2.5mg............................... 42
dronabinol cap 5mg ................................. 42
duloxetine cap 20mg ................................ 36
duloxetine cap 30mg ................................ 36
duloxetine cap 60mg ................................ 36
duramorph inj 0.5mg/ml ............................. 5
duramorph inj 1mg/ml ................................ 5
durezol emu 0.05% ................................ 157
dyrenium cap 100mg.............................. 110
dyrenium cap 50mg ............................... 111
E
ecee plus tab....................................... 177
econazole cre 1% .................................. 123
edarbi tab 40mg ....................................... 94
edarbi tab 80mg ....................................... 94
edarbyclor tab 40-12.5 ............................. 99
edarbyclor tab 40-25mg ........................... 99
edurant tab 25mg ..................................... 72
effient tab 10mg ....................................... 92
effient tab 5mg ......................................... 92
elaprase inj 6mg/3ml .............................. 128
eldertonic elx ........................................ 177
elidel cre 1% .......................................... 123
eligard inj 22.5mg..................................... 52
eligard inj 30mg........................................ 52
eligard inj 45mg........................................ 52
eligard inj 7.5mg....................................... 52
elitek inj 1.5mg ......................................... 52
ella tab 30mg ......................................... 140
ellence inj 2mg/ml .................................... 52
elmiron cap 100mg .................................136
embeda cap 100-4mg ............................... 1
embeda cap 20-0.8mg .............................. 1
embeda cap 30-1.2mg .............................. 1
embeda cap 50-2mg ................................. 1
embeda cap 60-2.4mg .............................. 1
embeda cap 80-3.2mg .............................. 1
emcyt cap 140mg .....................................52
emend cap 125mg ...................................42
emend cap 40mg .....................................42
emend cap 80mg .....................................42
emend pak 80 & 125 ................................42
emsam dis 12mg/24h ...............................35
emsam dis 6mg/24hr ................................36
emsam dis 9mg/24hr ................................36
emtriva cap 200mg ...................................73
emtriva sol 10mg/ml .................................73
enablex tab 15mg ...................................134
enablex tab 7.5mg ..................................134
enalapr/hctz tab 10-25mg .......................100
enalapr/hctz tab 5-12.5mg ......................100
enalapril tab 10mg ....................................95
enalapril tab 2.5mg ...................................95
enalapril tab 20mg ....................................95
enalapril tab 5mg ......................................95
enbrel inj 25/0.5ml ..................................148
enbrel inj 25mg.......................................148
enbrel inj 50mg/ml ..................................148
endacof-dm liq 2.5-1-5 .........................167
endocet tab 10-325mg .............................. 5
endocet tab 5-325mg ................................ 5
endocet tab 7.5-325 .................................. 5
enemeez plus ene 20-283 ......................134
engerix-b inj 10/0.5ml .............................151
engerix-b inj 20mcg/ml ...........................151
enoxaparin inj 100mg/ml ..........................88
enoxaparin inj 120/0.8 ..............................88
enoxaparin inj 150mg/ml ..........................88
enoxaparin inj 30/0.3ml ............................88
enoxaparin inj 300/3ml .............................89
enoxaparin inj 40/0.4ml ............................89
enoxaparin inj 60/0.6ml ............................89
enoxaparin inj 80/0.8ml ............................89
entacapone tab 200mg.............................62
entecavir tab 0.5mg ..................................77
entecavir tab 1mg .....................................77
enulose sol 10gm/15 ..............................130
epipen 2-pak inj 0.3mg ...........................155
epipen-jr inj 2-pak ...................................155
epirubicin inj 50/25ml................................52
epitol tab 200mg.......................................31
epivir hbv sol 5mg/ml ............................... 73
eplerenone tab 25mg ............................. 111
eplerenone tab 50mg ............................. 111
eprosart mes tab 600mg .......................... 94
epzicom tab 600-300................................ 73
equetro cap 100mg .................................. 31
equetro cap 200mg .................................. 31
equetro cap 300mg .................................. 31
eraxis inj 100mg ....................................... 44
erbitux inj 100mg...................................... 52
ergocalcifer sol 8000/ml ......................... 177
ergoloid mes tab 1mg oral ........................ 32
ergomar sub 2mg ..................................... 46
erivedge cap 150mg ................................ 52
erwinaze inj 10000unt .............................. 52
erythrocin inj 500mg ................................. 21
erythrocin tab 250mg ............................... 21
erythrom eth tab 400mg ........................... 21
erythromycin gel /benzoyl ...................... 123
erythromycin gel 2%............................... 123
erythromycin oin op ................................ 156
erythromycin sol 2% ............................... 123
esbriet cap 267mg ................................. 165
escitalopram sol 5mg/5ml ........................ 36
escitalopram tab 10mg ............................. 36
escitalopram tab 20mg ............................. 36
escitalopram tab 5mg ............................... 36
esomeprazole cap 49.3mg ..................... 131
estazolam tab 1mg ................................. 169
estazolam tab 2mg ................................. 169
estradiol tab 0.5mg ................................ 140
estradiol tab 1mg ................................... 140
estradiol tab 2mg ................................... 140
ethambutol tab 100mg ............................. 47
ethambutol tab 400mg ............................. 47
ethosuximide cap 250mg ......................... 25
ethosuximide sol 250/5ml ......................... 26
etodolac cap 200mg ................................. 10
etodolac cap 300mg ................................. 10
etodolac er tab 400mg ............................. 10
etodolac er tab 500mg ............................. 10
etodolac er tab 600mg ............................. 10
etodolac tab 400mg ................................. 10
etodolac tab 500mg ................................. 10
etopophos inj 100mg ................................ 52
etoposide inj 500/25ml ............................. 53
eurax cre 10% ........................................ 123
evotaz tab 300-150 .................................. 73
exelon dis 13.3/24 .................................... 32
exelon dis 4.6mg/24 ................................. 32
exelon dis 9.5mg/24 ................................. 33
exemestane tab 25mg ..............................61
exjade tab 125mg ...................................170
exjade tab 250mg ...................................170
exjade tab 500mg ...................................170
extavia inj 0.3mg ....................................119
extra action syp 100-10/5 .......................167
F
fabrazyme inj 35mg ................................128
famciclovir tab 125mg ..............................78
famciclovir tab 250mg ..............................78
famciclovir tab 500mg ..............................78
famotidine tab 10mg .............................134
famotidine inj 10mg/ml ...........................130
famotidine inj 20mg/50m ........................130
famotidine tab 20mg ...............................130
famotidine tab 40mg ...............................130
fanapt pak ................................................68
fanapt tab 10mg .......................................68
fanapt tab 12mg .......................................68
fanapt tab 1mg .........................................68
fanapt tab 2mg .........................................68
fanapt tab 4mg .........................................68
fanapt tab 6mg .........................................68
fanapt tab 8mg .........................................68
fareston tab 60mg ....................................53
farxiga tab 10mg ......................................83
farxiga tab 5mg ........................................83
farydak cap 10mg .....................................53
farydak cap 15mg .....................................53
farydak cap 20mg .....................................53
faslodex inj 250mg ...................................53
fazaclo tab 150mg ....................................71
fazaclo tab 200mg ....................................71
felbamate sus 600/5ml .............................27
felbamate tab 400mg................................27
felbamate tab 600mg................................28
felodipine tab 10mg er ............................107
felodipine tab 2.5mg er ...........................107
felodipine tab 5mg er ..............................107
fenofibrate cap 134mg............................112
fenofibrate cap 150mg............................112
fenofibrate cap 200mg............................112
fenofibrate cap 50mg..............................112
fenofibrate cap 67mg..............................112
fenofibrate tab 145mg ............................112
fenofibrate tab 160mg ............................112
fenofibrate tab 48mg ..............................112
fenofibrate tab 54mg ..............................112
fenoprofen tab 600mg ..............................10
fentanyl dis 100mcg/h ............................... 1
fentanyl dis 12mcg/hr ................................. 1
fentanyl dis 25mcg/hr ................................. 1
fentanyl dis 37.5mcg .................................. 1
fentanyl dis 50mcg/hr ................................. 1
fentanyl dis 62.5mcg .................................. 1
fentanyl dis 75mcg/hr ................................. 1
fentanyl dis 87.5mcg .................................. 1
fentora tab 200mcg .................................... 5
fentora tab 400mcg .................................... 5
fentora tab 600mcg .................................... 5
fentora tab 800mcg .................................... 5
ferrex 150 cap 150mg .......................... 177
ferrous gluc tab 324mg .......................... 177
ferrous sulf tab 325mg fc........................ 177
fetzima cap 120mg ................................... 37
fetzima cap 20mg..................................... 37
fetzima cap 40mg..................................... 37
fetzima cap 80mg..................................... 37
fetzima cap titratio .................................. 156
fexofenadine tab 60mg........................... 166
fiber laxatv tab 625mg ............................ 132
fiber therap pow 58.6% .......................... 132
fiber therap tab 500mg ........................... 132
fibercon tab 625mg ............................ 132
finasteride tab 5mg ................................ 135
firazyr inj 30mg/3ml ................................ 156
firmagon inj 120mg .................................. 53
firmagon inj 80mg .................................... 53
flebogamma inj dif 10% .......................... 150
flecainide tab 100mg ................................ 96
flecainide tab 150mg ................................ 96
flecainide tab 50mg .................................. 96
flovent disk aer 100mcg ......................... 161
flovent disk aer 250mcg ......................... 161
flovent disk aer 50mcg ........................... 161
flovent hfa aer 110mcg........................... 161
flovent hfa aer 220mcg........................... 161
flovent hfa aer 44mcg............................. 161
fluconazole sus 10mg/ml.......................... 44
fluconazole sus 40mg/ml.......................... 44
fluconazole tab 100mg ............................. 44
fluconazole tab 150mg ............................. 44
fluconazole tab 200mg ............................. 44
fluconazole tab 50mg ............................... 44
fluconazole/ inj dex 400............................ 44
flucytosine cap 250mg ............................. 44
flucytosine cap 500mg ............................. 44
fludarabine inj 50mg ................................. 49
fludrocort tab 0.1mg ............................... 138
flunisolide spr 0.025% ............................ 164
fluocin acet cre 0.01% ............................ 123
fluocin acet cre 0.025% ..........................123
fluocin acet oil 0.01% .............................160
fluocin acet oil body ................................123
fluocin acet oin 0.025% ..........................123
fluocin acet sol 0.01% ............................123
fluocinonide cre -e 0.05% .......................123
fluocinonide gel 0.05% ...........................123
fluocinonide oin 0.05% ...........................123
fluocinonide sol 0.05% ...........................123
fluorouracil cre 0.5%...............................123
fluorouracil cre 5% .................................123
fluorouracil inj 2.5g/50m ...........................53
fluorouracil sol 2% ....................................53
fluorouracil sol 5% ....................................53
fluoxetine cap 10mg .................................37
fluoxetine cap 20mg .................................37
fluoxetine cap 40mg .................................37
fluoxetine cap 90mg dr .............................37
fluoxetine sol 20mg/5ml............................37
fluoxetine tab 10mg ..................................37
fluoxetine tab 20mg ..................................37
fluoxetine tab 60mg ..................................37
fluphenaz de inj 25mg/ml .........................65
fluphenazine con 5mg/ml .........................65
fluphenazine elx 2.5/5ml ...........................65
fluphenazine inj 2.5mg/ml .........................65
fluphenazine tab 10mg .............................65
fluphenazine tab 1mg ...............................65
fluphenazine tab 2.5mg ............................65
fluphenazine tab 5mg ...............................65
flurazepam cap 15mg .............................169
flurazepam cap 30mg .............................169
flurbiprofen sol 0.03% op ........................157
flurbiprofen tab 100mg .............................10
flurbiprofen tab 50mg ...............................10
flutamide cap 125mg ................................53
fluticasone cre 0.05% .............................123
fluticasone oin 0.005% ...........................123
fluticasone spr 50mcg ............................164
fluvastatin cap 20mg ..............................113
fluvastatin cap 40mg ..............................113
fluvoxamine cap 100mg er .......................37
fluvoxamine cap 150mg er .......................37
fluvoxamine tab 100mg ............................37
fluvoxamine tab 25mg ..............................37
fluvoxamine tab 50mg ..............................37
foam antacid chw 80-20mg ....................132
folic acid tab 1mg .................................177
folic acid tab 400mcg............................177
folotyn inj 40mg/2ml .................................53
fondaparinux sol 10/0.8 ............................89
fondaparinux sol 2.5/0.5 ........................... 89
fondaparinux sol 5.0/0.4 ........................... 89
fondaparinux sol 7.5/0.6 ........................... 89
forfivo xl tab 450mg .................................. 34
forteo sol 600/2.4 ................................... 154
fosamax + d tab 70-2800 ....................... 154
fosamax + d tab 70-5600 ....................... 154
foscarnet inj 24mg/ml ............................... 72
fosfree
tab ......................................... 177
fosinop/hctz tab 10/12.5 ......................... 100
fosinop/hctz tab 20/12.5 ......................... 100
fosinopril tab 10mg ................................... 95
fosinopril tab 20mg ................................... 95
fosinopril tab 40mg ................................... 95
fosphenytoin inj 100/2ml .......................... 31
fosrenol chw 1000mg ............................. 136
fosrenol chw 500mg ............................... 136
fosrenol chw 750mg ............................... 136
fragmin inj 7500/0.3 ................................. 89
fragmin inj 95000unt ................................ 89
freamine hbc inj 6.9%............................. 175
fulyzaq tab 125mg .................................. 129
furosemide inj 10mg/ml .......................... 110
furosemide sol 10mg/ml ......................... 110
furosemide sol 8mg/ml ........................... 110
furosemide tab 20mg ............................. 110
furosemide tab 40mg ............................. 110
furosemide tab 80mg ............................. 110
fusilev inj 50mg ........................................ 53
fuzeon inj 90mg........................................ 74
fycompa tab 10mg ................................... 26
fycompa tab 12mg ................................... 26
fycompa tab 2mg ..................................... 26
fycompa tab 4mg ..................................... 26
fycompa tab 6mg ..................................... 26
fycompa tab 8mg ..................................... 27
G
gabapentin cap 100mg............................. 27
gabapentin cap 300mg............................. 27
gabapentin cap 400mg............................. 27
gabapentin sol 250/5ml ............................ 27
gabapentin tab 600mg ............................. 27
gabapentin tab 800mg ............................. 27
gabitril tab 12mg ...................................... 27
gabitril tab 16mg ...................................... 27
galantamine cap 16mg er ......................... 33
galantamine cap 24mg er ......................... 33
galantamine cap 8mg er........................... 33
galantamine sol 4mg/ml ........................... 33
galantamine tab 12mg.............................. 33
galantamine tab 4mg ................................33
galantamine tab 8mg ................................33
gamastan s/d inj .....................................150
gammagard inj 2.5gm/25 ........................150
gammaked inj 1gm/10ml ........................150
gammaplex inj 10gm ..............................150
gamunex-c inj 1gm/10ml ........................150
ganciclovir inj 500mg ................................72
gardasil 9 inj ...........................................151
gardasil inj ..............................................152
gauze pads & dressings - pads ................83
gaviscon chw......................................132
gaviscon chw ex-str ............................133
gaviscon sus ......................................133
gemcitabine inj 1gm .................................49
gemfibrozil tab 600mg ............................112
generlac sol 10gm/15 .............................131
gengraf cap 100mg ................................148
gengraf cap 25mg ..................................148
gengraf sol 100mg/ml .............................148
gentak oin 0.3% op ................................156
gentam/nacl inj 0.9mg/ml .........................14
gentam/nacl inj 1.4mg/ml .........................14
gentam/nacl inj 100mg .............................14
gentam/nacl inj 60mg ...............................14
gentam/nacl inj 80mg ...............................14
gentamicin cre 0.1% ...............................124
gentamicin inj 10mg/ml.............................14
gentamicin inj 40mg/ml.............................14
gentamicin oin 0.1% ...............................124
gentamicin sol 0.3% op ..........................157
genteal
dro opth ................................159
genteal
gel.........................................159
genteal
gel 0.3%................................159
geodon inj 20mg.......................................68
geravim
liq .........................................177
gilenya cap 0.5mg ..................................119
gilotrif tab 20mg........................................53
gilotrif tab 30mg........................................53
gilotrif tab 40mg........................................53
gleevec tab 100mg ...................................53
gleevec tab 400mg ...................................53
gleostine cap 100mg ................................48
gleostine cap 10mg ..................................48
gleostine cap 40mg ..................................48
glimepiride tab 1mg ..................................83
glimepiride tab 2mg ..................................83
glimepiride tab 4mg ..................................83
glip/metform tab 2.5-250m........................83
glip/metform tab 2.5-500m........................83
glip/metform tab 5-500mg ........................83
glipizide er tab 10mg ................................ 83
glipizide er tab 2.5mg ............................... 83
glipizide er tab 5mg .................................. 83
glipizide tab 10mg .................................... 83
glipizide tab 5mg ...................................... 83
glucagen inj hypokit ................................. 87
glucagon kit 1mg ...................................... 87
glumetza tab 1000mg............................... 83
glumetza tab 500mg ................................ 83
glyb/metform tab 1.25-250 ....................... 83
glyb/metform tab 2.5-500 ......................... 83
glyb/metform tab 5-500mg ....................... 83
glyburid mcr tab 1.5mg............................. 83
glyburid mcr tab 3mg................................ 84
glyburid mcr tab 6mg................................ 84
glyburide tab 1.25mg................................ 84
glyburide tab 2.5mg ................................. 84
glyburide tab 5mg .................................... 84
gnp all day tab allergy ........................... 166
gnp allergy tab 180mg............................. 43
gnp aspirin tab 325mg ec ........................ 13
gnp clearlax pow .................................... 134
gnp enema ene ................................... 133
gnp milk mag sus ................................... 133
granisetron inj 0.1mg/ml ........................... 42
granisetron inj 1mg/ml .............................. 42
granisetron tab 1mg ................................. 42
griseofulvin sus 125/5ml........................... 44
guaifenesin tab 600mg er ...................... 167
guanfacine tab 1mg er ........................... 117
guanfacine tab 2mg er ........................... 117
guanfacine tab 3mg er ........................... 117
guanfacine tab 4mg er ........................... 117
guanidine tab 125mg................................ 46
H
halaven inj 1mg/2ml ................................. 54
halobetasol cre 0.05%............................ 124
halobetasol oin 0.05% ............................ 124
haloper dec inj 100mg/ml ......................... 65
haloper dec inj 50mg/ml ........................... 65
haloper lac inj 5mg/ml .............................. 65
haloperidol con 2mg/ml ............................ 65
haloperidol tab 0.5mg............................... 65
haloperidol tab 10mg................................ 65
haloperidol tab 1mg ................................. 65
haloperidol tab 20mg................................ 66
haloperidol tab 2mg ................................. 66
haloperidol tab 5mg ................................. 66
harvoni tab 90-400mg .............................. 77
havrix inj 1440unit .................................. 152
havrix inj 720unit ....................................152
hc valerate cre 0.2%...............................124
hc valerate oin 0.2% ...............................124
hep sod/d5w inj 20000unt.........................89
hep sod/d5w inj 25000unt.........................89
heparin sod inj 1000/ml ............................89
heparin sod inj 10000/ml ..........................89
heparin sod inj 20000/ml ..........................89
heparin sod inj 5000/ml ............................90
hepatamine sol 8% .................................175
herceptin inj 440mg ..................................54
hexalen cap 50mg ....................................48
hm ibuprofen tab 200mg ..........................13
humatrope inj 12mg................................142
humatrope inj 24mg................................142
humira inj 10mg/0.2 ................................148
humira kit 20mg/0.4 ................................148
humira kit 40mg/0.8 ................................148
humira pen kit crohns .............................148
hydralazine inj 20mg/ml..........................114
hydralazine tab 100mg ...........................115
hydralazine tab 10mg .............................115
hydralazine tab 25mg .............................115
hydralazine tab 50mg .............................115
hydro skin lot 1% ..................................127
hydrochlorot cap 12.5mg ........................111
hydrochlorot tab 12.5mg .........................111
hydrochlorot tab 25mg............................111
hydrochlorot tab 50mg............................111
hydroco/apap sol 7.5-325 .......................... 5
hydroco/apap tab 10-325mg...................... 5
hydroco/apap tab 2.5-325 ......................... 5
hydroco/apap tab 5-325mg........................ 5
hydroco/apap tab 7.5-325 ......................... 5
hydrocod/ibu tab 7.5-200 ........................... 5
hydrocort cre 1% ....................................124
hydrocort cre 2.5% .................................124
hydrocort lot 2.5% ..................................124
hydrocort oin 1% ....................................124
hydrocort oin 2.5% .................................124
hydrocort tab 10mg ................................138
hydrocort tab 5mg ..................................138
hydromorphon inj 500/50ml ....................... 6
hydromorphon liq 1mg/ml .......................... 6
hydromorphon tab 2mg ............................. 6
hydromorphon tab 4mg ............................. 6
hydromorphon tab 8mg ............................. 6
hydroxychlor tab 200mg ...........................61
hydroxyurea cap 500mg ...........................54
hydroxyz hcl inj 25mg/ml ..........................79
hydroxyz hcl inj 50mg/ml ..........................79
hydroxyz hcl sol 10mg/5ml ....................... 79
hydroxyz hcl tab 10mg ............................. 79
hydroxyz hcl tab 25mg ............................. 79
hydroxyz hcl tab 50mg ............................. 79
hydroxyz pam cap 100mg ........................ 79
hydroxyz pam cap 25mg .......................... 79
hydroxyz pam cap 50mg .......................... 79
I
ibrance cap 100mg .................................. 54
ibrance cap 125mg .................................. 54
ibrance cap 75mg .................................... 54
ibuprofen cap 200mg ............................ 13
ibuprofen sus 100/5ml .............................. 10
ibuprofen tab 400mg ................................ 11
ibuprofen tab 600mg ................................ 11
ibuprofen tab 800mg ................................ 11
iclusig tab 15mg ....................................... 54
iclusig tab 45mg ....................................... 54
idamycin pfs inj 20/20ml ........................... 54
idarubicin inj 10/10ml ............................... 54
ifex inj 1gm............................................... 54
ifosfamide inj 1gm .................................... 54
ilaris inj 180mg ....................................... 151
imbruvica cap 140mg ............................... 54
imipenem/cil inj 250mg............................. 18
imipenem/cil inj 500mg............................. 18
imipram hcl tab 10mg ............................... 41
imipram hcl tab 25mg ............................... 41
imipram hcl tab 50mg ............................... 41
imipram pam cap 100mg .......................... 41
imipram pam cap 125mg .......................... 41
imipram pam cap 150mg .......................... 41
imipram pam cap 75mg............................ 41
imiquimod cre 5% .................................. 124
imovax rabie inj 2.5/ml ........................... 152
increlex inj 40mg/4ml ............................. 142
indapamide tab 1.25mg.......................... 111
indapamide tab 2.5mg............................ 111
indomethacin cap 25mg ........................... 11
indomethacin cap 50mg ........................... 11
indomethacin cap 75mg er ....................... 11
infanrix inj............................................... 152
inlyta tab 1mg .......................................... 54
inlyta tab 5mg .......................................... 54
insta-glucos gel 40% ................................ 87
insulin pen needle .................................... 84
insulin syringe (disp) u-100 ...................... 84
intelence tab 100mg ................................. 72
intelence tab 200mg ................................. 72
intelence tab 25mg ................................... 72
intralipid inj 20% .....................................175
intron a inj 18mu.......................................54
intron a inj 50mu.......................................54
intron-a inj 10mu ......................................54
intron-a inj 18mu ......................................54
invanz inj 1gm ..........................................18
invega sust inj 117/0.75............................68
invega sust inj 156mg/ml ..........................68
invega sust inj 234/1.5..............................68
invega sust inj 39/0.25..............................68
invega sust inj 78/0.5ml ............................68
invega tab 1.5mg ......................................68
invega tab 3mg.........................................68
invega tab 6mg.........................................68
invega tab 9mg.........................................68
invirase cap 200mg ..................................75
invirase tab 500mg ...................................75
invokamet tab 150-1000 ...........................84
invokamet tab 150-500 .............................84
invokamet tab 50-1000 .............................84
invokamet tab 50-500mg ..........................84
invokana tab 100mg .................................84
invokana tab 300mg .................................84
ipol inj inactive ........................................152
ipratropium sol 0.02%inh ........................162
ipratropium spr 0.03% ............................164
ipratropium spr 0.06% ............................164
ipratropium/ sol albuter ...........................163
irbesartan tab 150mg ...............................94
irbesartan tab 300mg ...............................94
irbesartan tab 75mg .................................94
irinotecan inj 100/5ml ...............................54
isentress chw 100mg................................74
isentress chw 25mg..................................75
isentress pow 100mg ...............................75
isentress tab 400mg .................................75
isolyte-p inj /d5w.....................................171
isolyte-s inj .............................................171
isoniazid inj 100mg/ml ..............................47
isoniazid syp 50mg/5ml ............................47
isoniazid tab 100mg .................................47
isoniazid tab 300mg .................................47
isopropyl alcohol 0.7 ml/ml .......................84
isosorb din tab 10mg ..............................115
isosorb din tab 20mg ..............................115
isosorb din tab 30mg ..............................115
isosorb din tab 40mg er ..........................115
isosorb din tab 5mg ................................115
isosorb mono tab 10mg ..........................115
isosorb mono tab 120mg er ....................115
isosorb mono tab 20mg ..........................115
isosorb mono tab 30mg er ..................... 115
isosorb mono tab 60mg er ..................... 115
isradipine cap 2.5mg .............................. 107
isradipine cap 5mg ................................. 107
istodax inj 10mg ....................................... 54
itraconazole cap 100mg ........................... 44
ivermectin tab 3mg ................................... 61
ixempra kit inj 45mg ................................. 55
ixiaro inj.................................................. 152
J
jakafi tab 10mg......................................... 55
jakafi tab 15mg......................................... 55
jakafi tab 20mg......................................... 55
jakafi tab 25mg......................................... 55
jakafi tab 5mg .......................................... 55
jalyn cap................................................. 135
jantoven tab 10mg ................................... 90
jantoven tab 1mg ..................................... 90
jantoven tab 2.5mg .................................. 90
jantoven tab 2mg ..................................... 90
jantoven tab 3mg ..................................... 90
jantoven tab 4mg ..................................... 90
jantoven tab 5mg ..................................... 90
jantoven tab 6mg ..................................... 90
jantoven tab 7.5mg .................................. 90
janumet tab 50-1000 ................................ 84
janumet tab 50-500mg ............................. 84
janumet xr tab 100-1000 .......................... 85
janumet xr tab 50-1000 ............................ 85
janumet xr tab 50-500mg ......................... 85
januvia tab 100mg .................................... 85
januvia tab 25mg...................................... 85
januvia tab 50mg...................................... 85
jevtana inj 60/1.5ml .................................. 55
juxtapid cap 10mg .................................. 114
juxtapid cap 20mg .................................. 114
juxtapid cap 5mg .................................... 114
K
kadcyla inj 100mg .................................... 55
kaletra sol ................................................ 75
kaletra tab 100-25mg ............................... 75
kaletra tab 200-50mg ............................... 76
kalydeco pak 50mg ................................ 165
kalydeco pak 75mg ................................ 165
kalydeco tab 150mg ............................... 165
kazano 12.5- tab 1000mg ........................ 85
kazano 12.5- tab 500mg .......................... 85
kcl in nacl inj .......................................... 171
kcl/d5w inj 0.15% ................................... 171
kcl/d5w inj 0.3% .....................................171
kcl/d5w/lr inj 0.15% ................................171
kcl/d5w/nacl inj .075/.45 .........................171
kcl/d5w/nacl inj .15/.33% ........................171
kcl/d5w/nacl inj .15/.45% ........................171
kcl/d5w/nacl inj .22/.45 ...........................171
kcl/d5w/nacl inj 0.15/0.2 .........................171
kcl/d5w/nacl inj 0.3/0.45 .........................171
kcl/nacl inj 0.15-0.9 ................................171
kepivance inj 6.25mg................................55
ketek tab 300mg.......................................21
ketek tab 400mg.......................................21
ketoconazole cre 2% ..............................124
ketoconazole sha 2% .............................124
ketoconazole tab 200mg ..........................44
ketoprofen cap 200mg er .........................11
ketoprofen cap 50mg................................11
ketoprofen cap 75mg................................11
ketorolac inj 15mg/ml ...............................11
ketorolac inj 30mg/ml ...............................11
ketorolac sol 0.4% ..................................157
ketorolac sol 0.5% ..................................158
ketorolac tab 10mg ...................................11
keytruda sol 50mg ....................................55
khedezla tab 100mg er .............................37
khedezla tab 50mg er ...............................37
kidkare
liq cgh/cold ............................167
kineret inj................................................149
kionex pow .............................................170
klor-con 10 tab 10meq er .......................171
klor-con 8 tab 8meq er ...........................171
klor-con m20 tab 20meq er.....................171
kombiglyze tab 2.5-1000 ..........................85
kombiglyze tab 5-1000mg ........................85
kombiglyze tab 5-500mg ..........................85
konsyl
pow 100% .............................133
konsyl
pow 30.9% ............................133
konsyl
pow 71.67% ..........................133
konsyl-d pow 52.3% ...........................133
korlym tab 300mg ...................................146
kuvan tab 100mg ....................................128
kynamro inj 200mg/ml ............................114
L
labetalol inj 5mg/ml ................................104
labetalol tab 100mg ................................104
labetalol tab 200mg ................................104
labetalol tab 300mg ................................104
lactated rin inj .........................................172
lactated rin sol irrigat ..............................156
lactulose sol 10gm/15.............................131
lamictal kit start 35 ................................... 28
lamictal kit start 49 ................................... 28
lamictal kit start 98 ................................... 28
lamictal xr kit ............................................ 28
lamisil af aer 1%................................... 127
lamivud/zido tab 150-300 ......................... 73
lamivudine sol 10mg/ml............................ 73
lamivudine tab 100mg .............................. 73
lamivudine tab 150mg .............................. 73
lamivudine tab 300mg .............................. 73
lamotrigine chw 25mg .............................. 28
lamotrigine chw 5mg ................................ 28
lamotrigine tab 100mg.............................. 28
lamotrigine tab 100mg er ......................... 28
lamotrigine tab 150mg.............................. 28
lamotrigine tab 200mg.............................. 28
lamotrigine tab 200mg er ......................... 28
lamotrigine tab 250mg er ......................... 28
lamotrigine tab 25mg................................ 28
lamotrigine tab 25mg er ........................... 28
lamotrigine tab 300mg er ......................... 28
lamotrigine tab 50mg er ........................... 28
lamotrigine tab odt 25mg .......................... 28
lamotrigine tab odt 50mg .......................... 29
lamotrigine tab odt/100............................. 29
lamotrigine tab odt/200............................. 29
lantus inj 100/ml ....................................... 88
lantus inj solostar ..................................... 88
latanoprost sol 0.005%........................... 156
latuda tab 120mg ..................................... 68
latuda tab 20mg ....................................... 69
latuda tab 40mg ....................................... 69
latuda tab 60mg ....................................... 69
latuda tab 80mg ....................................... 69
lazanda spr 100mcg ................................... 6
lazanda spr 400mcg ................................... 6
leflunomide tab 10mg ............................. 151
leflunomide tab 20mg ............................. 151
lenvima cap 10mg .................................... 55
lenvima cap 14mg .................................... 55
lenvima cap 20mg .................................... 55
lenvima cap 24mg .................................... 55
lescol xl tab 80mg .................................. 113
letairis tab 10mg..................................... 164
letairis tab 5mg....................................... 164
letrozole tab 2.5mg .................................. 61
leucovor ca inj 100mg .............................. 55
leucovor ca inj 350mg .............................. 55
leucovor ca tab 10mg ............................... 55
leucovor ca tab 15mg ............................... 55
leucovor ca tab 25mg ............................... 55
leucovor ca tab 5mg .................................55
leukeran tab 2mg .....................................48
leukine inj 250mcg ...................................91
leuprolide inj 1mg/0.2 ...............................55
levemir inj .................................................88
levemir inj flextouc ....................................88
levetiraceta inj 10mg/ml............................23
levetiraceta inj 15mg/ml............................24
levetiraceta inj 5mg/ml..............................24
levetiraceta sol 100mg/ml .........................24
levetiraceta tab 1000mg ...........................24
levetiraceta tab 250mg .............................24
levetiraceta tab 500mg .............................24
levetiraceta tab 500mg er .........................24
levetiraceta tab 750mg .............................24
levetiraceta tab 750mg er .........................24
levetiracetm inj 500/5ml............................24
levobunolol sol 0.5% op .........................159
levocarnitin inj 200mg/ml ........................128
levocarnitin sol 1gm/10ml .......................128
levocarnitin tab 330mg ...........................128
levoflox/d5w inj 500/100m ........................22
levofloxacin inj 25mg/ml ...........................22
levofloxacin sol 25mg/ml ..........................22
levofloxacin tab 250mg.............................22
levofloxacin tab 500mg.............................22
levofloxacin tab 750mg.............................22
levoleucovor inj 50mg...............................55
levothyroxin tab 100mcg ........................143
levothyroxin tab 112mcg ........................143
levothyroxin tab 125mcg ........................143
levothyroxin tab 137mcg ........................143
levothyroxin tab 150mcg ........................143
levothyroxin tab 175mcg ........................143
levothyroxin tab 200mcg ........................143
levothyroxin tab 25mcg ..........................143
levothyroxin tab 300mcg ........................143
levothyroxin tab 50mcg ..........................143
levothyroxin tab 75mcg ..........................143
levothyroxin tab 88mcg ..........................143
levoxyl tab 100mcg ................................143
levoxyl tab 112mcg ................................143
levoxyl tab 125mcg ................................144
levoxyl tab 137mcg ................................144
levoxyl tab 150mcg ................................144
levoxyl tab 175mcg ................................144
levoxyl tab 200mcg ................................144
levoxyl tab 25mcg ..................................144
levoxyl tab 50mcg ..................................144
levoxyl tab 75mcg ..................................144
levoxyl tab 88mcg ..................................144
lexiva sus 50mg/ml .................................. 76
lexiva tab 700mg ...................................... 76
lice killing sha 0.33-4%........................... 127
lice treatme lot 1% ................................. 127
lice trtmnt liq crm rnse ........................... 127
lido/prilocn cre 2.5-2.5%............................. 8
lidocaine gel 2% jelly .......................... 8, 124
lidocaine inj 0.5% ....................................... 8
lidocaine inj 2% .......................................... 8
lidocaine oin 5% ..................................... 124
lidocaine sol 4% ..................................... 124
lidoderm dis 5% ..................................... 124
lincocin inj 300mg/ml ................................ 15
lindane lot 1% ........................................ 124
lindane sha 1% ...................................... 124
linezolid inj 2mg/ml ................................... 15
liothyronine tab 25mcg ........................... 144
liothyronine tab 50mcg ........................... 144
liothyronine tab 5mcg ............................. 144
liquitears sol ......................................... 159
lisinop/hctz tab 10-12.5 .......................... 100
lisinop/hctz tab 20-12.5 .......................... 100
lisinop/hctz tab 20-25mg ........................ 100
lisinopril tab 10mg .................................... 95
lisinopril tab 2.5mg ................................... 95
lisinopril tab 20mg .................................... 95
lisinopril tab 30mg .................................... 95
lisinopril tab 40mg .................................... 95
lisinopril tab 5mg ...................................... 95
lithium carb cap 150mg ............................ 81
lithium carb cap 300mg ............................ 81
lithium carb cap 600mg ............................ 81
lithium carb tab 300mg ............................. 81
lithium carb tab 300mg er ......................... 81
lithium carb tab 450mg er ......................... 81
lithium sol 8meq/5ml ................................ 81
livalo tab 1mg ......................................... 113
livalo tab 2mg ......................................... 113
livalo tab 4mg ......................................... 113
lokara lot 0.05% ..................................... 124
lomustine cap 100mg ............................... 48
lomustine cap 10mg ................................. 48
lomustine cap 40mg ................................. 48
loperamide liq 1mg/5ml ........................ 133
loperamide cap 2mg .............................. 129
loratadine syp 5mg/5ml ........................ 166
loratadine tab 10mg ............................. 166
lorazepam con 2mg/ml ............................. 81
lorazepam tab 0.5mg ............................... 81
lorazepam tab 1mg .................................. 81
lorazepam tab 2mg .................................. 81
lorcet plus tab 7.5-325 ............................... 1
losartan pot tab 100mg.............................94
losartan pot tab 25mg...............................94
losartan pot tab 50mg...............................94
losartan/hct tab 100-12.5 ........................100
losartan/hct tab 100-25...........................100
losartan/hct tab 50-12.5..........................100
lotronex tab 0.5mg .................................130
lotronex tab 1mg ....................................130
lovastatin tab 10mg ................................113
lovastatin tab 20mg ................................113
lovastatin tab 40mg ................................113
loxapine cap 10mg ...................................66
loxapine cap 25mg ...................................66
loxapine cap 50mg ...................................66
loxapine cap 5mg .....................................66
lumigan sol 0.01% ..................................156
lumizyme inj 50mg .................................128
lupr dep-ped inj 11.25mg ........................146
lupr dep-ped inj 15mg.............................146
lupron depot inj 11.25mg ........................146
lupron depot inj 22.5mg ............................56
lupron depot inj 3.75mg ............................56
lupron depot inj 30mg ...............................56
lupron depot inj 45mg ...............................56
lupron depot inj 7.5mg ..............................56
lynparza cap 50mg ...................................56
lyrica cap 100mg ....................................118
lyrica cap 150mg ....................................118
lyrica cap 200mg ......................................26
lyrica cap 225mg ......................................26
lyrica cap 25mg ........................................26
lyrica cap 300mg ......................................26
lyrica cap 50mg ........................................26
lyrica cap 75mg ........................................26
lyrica sol 20mg/ml ....................................26
lysodren tab 500mg ..................................56
lyza tab 0.35mg ......................................140
M
mag oxide tab 400mg ..........................177
mag oxide tab 420mg ..........................176
mag-delay tab .....................................178
magnebind tab 300..............................178
magnesium tab 250mg ........................178
magnesium tab 500mg ........................178
magnesium su inj 50% ...........................172
magonate tab 500mg .........................178
mapap
cap 500mg...........................166
mapap child tab 80mg rt ..........................13
maprotiline tab 25mg ................................34
maprotiline tab 50mg................................ 34
maprotiline tab 75mg................................ 34
marplan tab 10mg .................................... 36
matulane cap 50mg ................................. 56
meclizine tab 12.5mg ............................... 42
meclizine tab 25mg .................................. 42
meclofen sod cap 100mg ......................... 11
meclofen sod cap 50mg ........................... 11
medroxypr ac inj 150mg/ml .................... 140
medroxypr ac tab 10mg ......................... 141
medroxypr ac tab 2.5mg ........................ 141
medroxypr ac tab 5mg ........................... 142
mefloquine tab 250mg.............................. 61
megace es sus 625/5ml ........................... 56
megestrol ac sus 40mg/ml ....................... 56
megestrol ac tab 20mg............................. 56
megestrol ac tab 40mg............................. 56
mekinist tab 0.5mg ................................... 56
mekinist tab 2mg ...................................... 56
meloxicam sus 7.5/5ml............................. 11
meloxicam tab 15mg ................................ 11
meloxicam tab 7.5mg ............................... 11
melphalan inj 50mg .................................. 56
menactra inj ........................................... 152
menest tab 0.3mg .................................. 141
menest tab 0.625mg .............................. 141
menest tab 1.25mg ................................ 141
menest tab 2.5mg .................................. 141
menomune inj a/c/y/w ............................ 152
menveo inj ............................................. 152
mephyton tab 5mg ............................. 178
meprobamate tab 200mg ......................... 79
meprobamate tab 400mg ......................... 79
mercaptopur tab 50mg ............................. 49
meribin
cap 5mg ............................... 178
meropenem inj 500mg ............................. 18
mesalamine kit 4gm ............................... 154
mesna inj 1gm.......................................... 56
mesnex tab 400mg .................................. 56
mestinon syp 60mg/5ml ........................... 46
metadate tab 20mg er ............................ 117
metformin er tab 1000mg ......................... 85
metformin tab 1000mg ............................. 85
metformin tab 500mg ............................... 85
metformin tab 500mg er ........................... 85
metformin tab 750mg er ........................... 85
metformin tab 850mg ............................... 85
methadone inj 10mg/ml .............................. 1
methadone sol 10mg/5ml ........................... 2
methadone sol 5mg/5ml ............................. 2
methadone tab 10mg ................................. 2
methadone tab 5mg .................................. 2
methazolamid tab 25mg .........................110
methazolamid tab 50mg .........................110
methimazole tab 10mg ...........................147
methimazole tab 5mg .............................147
methocarbam tab 500mg .......................168
methocarbam tab 750mg .......................169
methotrexate inj 1gm ................................49
methotrexate inj 1gm/40ml .......................49
methotrexate tab 2.5mg ...........................49
methoxsalen cap 10mg ..........................124
methscopolam tab 2.5mg .......................129
methyclothia tab 5mg .............................111
methyld/hctz tab 250/15 .........................100
methyld/hctz tab 250/25 .........................100
methyldopa tab 250mg .............................93
methyldopa tab 500mg .............................93
methyldopate inj 250/5ml .........................93
methylin chw 10mg ................................117
methylin chw 2.5mg................................117
methylin chw 5mg ..................................117
methylphenid cap 10mg .........................117
methylphenid sol 10mg/5ml ....................117
methylphenid sol 5mg/5ml ......................117
methylphenid tab 10mg ..........................117
methylphenid tab 20mg ..........................117
methylphenid tab 20mg er ......................118
methylphenid tab 27mg er ......................118
methylphenid tab 5mg ............................118
methylpr ace inj 40mg/ml .......................138
methylpr ace inj 80mg/ml .......................138
methylpr ss inj 125mg ............................138
methylpr ss inj 40mg ..............................138
methylpred pak 4mg ...............................138
methylpred tab 16mg..............................138
methylpred tab 32mg..............................138
methylpred tab 4mg................................138
methylpred tab 8mg................................138
metipranolol sol 0.3% oph ......................159
metoclopram inj 5mg/ml .........................129
metoclopram sol 5mg/5ml ......................129
metoclopram tab 10mg.............................42
metoclopram tab 5mg.............................129
metolazone tab 10mg .............................111
metolazone tab 2.5mg ............................111
metolazone tab 5mg ...............................111
metoprl/hctz tab 100-25mg .....................100
metoprl/hctz tab 100-50mg .....................100
metoprl/hctz tab 50-25mg .......................100
metoprol tar tab 100mg ..........................104
metoprol tar tab 25mg ............................104
metoprol tar tab 50mg ............................ 104
metoprolol inj 1mg/ml ............................. 104
metoprolol tab 100mg er ........................ 104
metoprolol tab 200mg er ........................ 104
metoprolol tab 25mg er .......................... 104
metoprolol tab 50mg er .......................... 104
metron/nacl inj 500mg .............................. 15
metronidazol cap 375mg .......................... 15
metronidazol cre 0.75% ......................... 124
metronidazol gel 0.75%.......................... 124
metronidazol gel 0.75%vag .................... 136
metronidazol lot 0.75%........................... 125
metronidazol tab 250mg........................... 15
metronidazol tab 500mg........................... 15
mexiletine cap 150mg .............................. 96
mexiletine cap 200mg .............................. 96
mexiletine cap 250mg .............................. 96
miacalcin inj 200/ml ................................ 154
mi-acid
chw ....................................... 133
miconazole sup 100mg ........................ 137
miconazole 3 sup 200mg ....................... 136
miconazole 7 cre 2% .............................. 137
midodrine tab 10mg ................................. 93
midodrine tab 2.5mg ................................ 93
midodrine tab 5mg ................................... 93
minitran dis 0.1mg/hr.............................. 115
minitran dis 0.2mg/hr.............................. 115
minitran dis 0.4mg/hr.............................. 115
minitran dis 0.6mg/hr.............................. 115
minocycline cap 100mg............................ 23
minocycline cap 50mg.............................. 23
minocycline cap 75mg.............................. 23
minocycline tab 100mg ............................ 23
minocycline tab 50mg .............................. 23
minocycline tab 75mg .............................. 23
minoxidil tab 10mg ................................. 115
minoxidil tab 2.5mg ................................ 115
mintox plus chw .................................... 133
miralax
pow 3350 nf .......................... 134
mircera inj 100mcg ................................... 91
mircera inj 50mcg ..................................... 91
mircera inj 75mcg ..................................... 91
mirtazapine tab 15mg............................... 35
mirtazapine tab 15mg odt ......................... 35
mirtazapine tab 30mg............................... 35
mirtazapine tab 30mg odt ......................... 35
mirtazapine tab 45mg............................... 35
mirtazapine tab 45mg odt ......................... 35
mirtazapine tab 7.5mg.............................. 35
misoprostol tab 100mcg ......................... 131
misoprostol tab 200mcg ......................... 131
mitomycin inj 20mg ..................................56
mitoxantron inj 2mg/ml .............................57
m-m-r ii inj live ........................................152
modafinil tab 100mg ...............................170
modafinil tab 200mg ...............................170
moexipr/hctz tab 15-12.5 ........................100
moexipr/hctz tab 15-25mg ......................101
moexipr/hctz tab 7.5-12.5 .......................101
moexipril tab 15mg ...................................95
moexipril tab 7.5mg ..................................95
mometasone cre 0.1% ...........................125
mometasone oin 0.1%............................125
montelukast chw 4mg.............................161
montelukast chw 5mg.............................162
montelukast gra 4mg ..............................162
montelukast tab 10mg ............................162
morphine sul cap 100mg er ....................... 2
morphine sul cap 10mg er ......................... 2
morphine sul cap 120mg er ....................... 2
morphine sul cap 20mg er ......................... 2
morphine sul cap 30mg er ......................... 2
morphine sul cap 45mg er ......................... 2
morphine sul cap 50mg er ......................... 2
morphine sul cap 60mg er ......................... 2
morphine sul cap 75mg er ......................... 2
morphine sul cap 80mg er ......................... 2
morphine sul cap 90mg er ......................... 2
morphine sul sol 10mg/5ml........................ 6
morphine sul sol 20mg/5ml........................ 6
morphine sul sol 20mg/ml ......................... 6
morphine sul tab 100mg er ........................ 3
morphine sul tab 15mg .............................. 6
morphine sul tab 15mg er .......................... 3
morphine sul tab 30mg .............................. 6
morphine sul tab 30mg er .......................... 3
morphine sul tab 60mg er .......................... 3
moxeza sol 0.5% ....................................157
mozobil inj ................................................91
mucinex nasl spr 0.05% .........................167
mucus relief liq 100/5ml..........................167
mucus relief liq 5-100mg ........................167
mucus relief tab 400mg ..........................168
mucus relief tab dm ................................168
multaq tab 400mg ....................................96
multi-delyn liq ........................................178
multi-delyn liq /iron ................................178
mupirocin oin 2%....................................125
muro 128 oin 5% op ...........................160
muro 128 sol 2% op ...........................160
muro 128 sol 5% op ...........................160
mustargen inj 10mg ..................................57
mycamine inj 100mg ................................ 44
mycamine inj 50mg .................................. 44
mycophenolat cap 250mg ...................... 149
mycophenolat sus 200mg/ml.................. 149
mycophenolat tab 500mg ....................... 149
mycophenolic tab 180mg dr ................... 149
mycophenolic tab 360mg dr ................... 149
myrbetriq tab 25mg ................................ 134
myrbetriq tab 50mg ................................ 135
N
nabumetone tab 500mg ........................... 11
nabumetone tab 750mg ........................... 11
nadolol tab 20mg ................................... 104
nadolol tab 40mg ................................... 104
nadolol tab 80mg ................................... 104
nadolol/bend tab 40-5mg ....................... 101
nadolol/bend tab 80-5mg ....................... 101
nafcillin inj 10gm ...................................... 20
nafcillin inj 1gm ........................................ 20
naglazyme inj 1mg/ml ............................ 128
nalbuphine inj 10mg/ml .............................. 6
nalbuphine inj 20mg/ml .............................. 6
naloxone inj 1mg/ml ................................... 8
naltrexone tab 50mg .................................. 8
namenda sol 10mg/5ml ............................ 33
namenda xr cap 14mg ............................. 33
namenda xr cap 21mg ............................. 33
namenda xr cap 28mg ............................. 33
namenda xr cap 7mg ............................... 33
namenda xr cap titratio............................. 33
naphazoline sol 0.1% op ........................ 156
naproxen dr tab 375mg ............................ 11
naproxen dr tab 500mg ............................ 12
naproxen sod tab 275mg ......................... 12
naproxen sod tab 550mg ......................... 12
naproxen sus 125/5ml .............................. 12
naproxen tab 250mg ................................ 12
naproxen tab 375mg ................................ 12
naproxen tab 500mg ................................ 12
nasal decong liq 30mg/5ml .................... 168
nasal decong tab 10mg .......................... 168
nasal decong tab 30mg .......................... 168
nasal saline spr 0.65% ........................... 164
nateglinide tab 120mg .............................. 85
nateglinide tab 60mg ................................ 86
natural bal sol 0.4% .............................. 160
nebupent inh 300mg ................................ 61
needles, insulin disp., safet ...................... 86
nefazodone tab 100mg ............................ 35
nefazodone tab 150mg ............................ 35
nefazodone tab 200mg.............................35
nefazodone tab 250mg.............................35
nefazodone tab 50mg...............................35
neo/bac/poly oin op ................................157
neo/poly gu sol 40/ml ir ..........................136
neo/poly/bac oin /hc 1%op .....................158
neo/poly/dex oin 0.1% op .......................158
neo/poly/dex sus 0.1% op ......................158
neo/poly/gra sol op .................................157
neo/poly/hc sol 1% otic...........................160
neo/poly/hc sus 1% otic..........................161
neo/poly/hc sus op .................................158
neomycin tab 500mg ................................14
nephramine inj 5.4%...............................175
nesina tab 12.5mg ....................................86
nesina tab 25mg.......................................86
nesina tab 6.25mg ....................................86
neumega inj 5mg ......................................91
neupogen inj 300/0.5 ................................91
neupogen inj 480/0.8 ................................91
neupogen inj 480mcg ...............................91
neupro dis 1mg/24hr ................................63
neupro dis 2mg/24hr ................................63
neupro dis 3mg/24hr ................................63
neupro dis 4mg/24hr ................................63
neupro dis 6mg/24hr ................................63
neupro dis 8mg/24hr ................................63
nevanac sus 0.1% ..................................158
nevirapine sus 50mg/5ml .........................72
nevirapine tab 200mg ...............................72
nevirapine tab 400mg er...........................72
nexavar tab 200mg ..................................57
niacin
tab 500mg tr ...........................178
niacin er tab 1000mg ..............................114
niacin er tab 500mg ................................114
niacin er tab 750mg ................................114
niacinamide tab 500mg .........................178
niacor tab 500mg ...................................114
nicardipine cap 20mg .............................107
nicardipine cap 30mg .............................107
nicorelief gum 2mg orig ........................... 9
nicorelief gum 4mg orig ........................... 9
nicorette loz 4mg orig ............................. 9
nicotine td dis 14mg/24h .......................... 9
nicotine td dis 21mg/24h .......................... 9
nicotine td dis 7mg/24hr ........................... 9
nicotrol inh................................................. 9
nifedical xl tab 30mg...............................107
nifedical xl tab 60mg...............................107
nifedipine cap 10mg ...............................107
nifedipine cap 20mg ...............................107
nifedipine tab 30mg er............................ 107
nifedipine tab 60mg er............................ 107
nifedipine tab 90mg er............................ 107
night time tab 25mg.............................. 166
nilandron tab 150mg ................................ 57
nimodipine cap 30mg ............................. 107
nipent inj 10mg......................................... 57
nisoldipine tab 20mg .............................. 107
nisoldipine tab 30mg .............................. 107
nisoldipine tab 40mg .............................. 108
nitrofur mac cap 50mg ............................. 15
nitrofurantn cap 100mg ............................ 15
nitroglycer dis 0.1mg/hr .......................... 115
nitroglycer dis 0.2mg/hr .......................... 116
nitroglycer dis 0.4mg/hr .......................... 116
nitroglycer inj 5mg/ml ............................. 116
nitroglyceri dis 0.6mg/hr ......................... 116
nitroglycrn spr 0.4mg.............................. 116
nitrostat sub 0.3mg ................................ 116
nitrostat sub 0.4mg ................................ 116
nitrostat sub 0.6mg ................................ 116
norethin ace tab 5mg ............................. 142
norethindron tab 0.35mg ........................ 140
normosol -m inj /d5w .............................. 172
normosol -r inj /d5w................................ 172
normosol-r inj ph 7.4 .............................. 172
northera cap 100mg ............................... 109
northera cap 200mg ............................... 109
northera cap 300mg ............................... 109
nortriptylin cap 10mg ................................ 41
nortriptylin cap 25mg ................................ 41
nortriptylin cap 50mg ................................ 41
nortriptylin cap 75mg ................................ 41
nortriptylin sol 10mg/5ml .......................... 41
norvir cap 100mg ..................................... 76
norvir sol 80mg/ml.................................... 76
norvir tab 100mg ...................................... 76
novolin inj 70/30 ....................................... 88
novolin n inj u-100 .................................... 88
novolin r inj u-100..................................... 88
novolog inj 100/ml .................................... 88
novolog inj flexpen ................................... 88
novolog mix inj 70/30 ............................... 88
novolog mix inj flexpen ............................. 88
noxafil sus 40mg/ml ................................. 44
noxafil tab 100mg..................................... 45
nucynta er tab 100mg ................................ 3
nucynta er tab 150mg ................................ 3
nucynta er tab 200mg ................................ 3
nucynta er tab 250mg ................................ 3
nucynta er tab 50mg .................................. 3
nucynta tab 100mg .................................... 6
nucynta tab 50mg ...................................... 6
nucynta tab 75mg ...................................... 7
nuedexta cap 20-10mg...........................118
nulojix inj 250mg ....................................149
nutropin aq inj 20mg/2ml ........................142
nutropin aq inj nuspin 5 ..........................142
nyamyc pow 100000 ..............................125
nystat/triam cre.......................................125
nystat/triam oin .......................................125
nystatin cre 100000 ................................125
nystatin oin 100000 ................................125
nystatin pow 100000 ..............................125
nystatin sus 100000 ...............................120
nystatin tab 500000 ..................................45
nystop pow 100000 ................................125
O
octreotide inj 1000mcg ...........................146
octreotide inj 100mcg .............................146
octreotide inj 200mcg .............................146
octreotide inj 500mcg .............................146
octreotide inj 50mcg/ml ..........................146
ofloxacin dro 0.3% op .............................157
ofloxacin dro 0.3%otic ............................161
ofloxacin tab 300mg .................................22
ofloxacin tab 400mg .................................22
olanza/fluox cap 12-25mg ........................37
olanza/fluox cap 12-50mg ........................38
olanza/fluox cap 3-25mg ..........................38
olanza/fluox cap 6-25mg ..........................38
olanza/fluox cap 6-50mg ..........................38
olanzapine inj 10mg .................................69
olanzapine tab 10mg ................................69
olanzapine tab 10mg odt ..........................69
olanzapine tab 15mg ................................69
olanzapine tab 15mg odt ..........................69
olanzapine tab 2.5mg ...............................69
olanzapine tab 20mg ................................69
olanzapine tab 20mg odt ..........................69
olanzapine tab 5mg ..................................69
olanzapine tab 5mg odt ............................69
olanzapine tab 7.5mg ...............................69
olysio cap 150mg .....................................77
omega-3-acid cap 1gm...........................114
omeprazole tab 20mg...........................134
omeprazole cap 10mg ............................131
omeprazole cap 20mg ............................131
omeprazole cap 40mg ............................131
oncaspar inj 750/ml ..................................57
once daily tab .......................................178
once daily tab iron ................................ 178
ondansetron inj 4mg/2ml .......................... 42
ondansetron sol 4mg/5ml ......................... 42
ondansetron tab 24mg ............................. 42
ondansetron tab 4mg ............................... 42
ondansetron tab 4mg odt ......................... 43
ondansetron tab 8mg ............................... 43
ondansetron tab 8mg odt ......................... 43
onfi sus 2.5mg/ml ..................................... 25
onfi tab 10mg ........................................... 25
onfi tab 20mg ........................................... 25
onglyza tab 2.5mg .................................... 86
onglyza tab 5mg....................................... 86
opana er tab 10mg ..................................... 3
opana er tab 15mg ..................................... 3
opana er tab 20mg ..................................... 3
opana er tab 30mg ..................................... 3
opana er tab 40mg ..................................... 3
opana er tab 5mg ....................................... 3
opana er tab 7.5mg .................................... 3
opdivo inj 40mg/4ml ................................. 57
opsumit tab 10mg .................................. 164
orap tab 1mg ............................................ 66
orap tab 2mg ............................................ 66
orapred odt tab 10mg ............................. 138
orencia inj 125mg/ml .............................. 151
orencia inj 250mg................................... 151
orfadin cap 10mg ................................... 128
orfadin cap 2mg ..................................... 128
orfadin cap 5mg ..................................... 128
orphenadrine inj 30mg/ml ....................... 169
orphenadrine tab 100mg er .................... 169
oseni tab 12.5-15 ..................................... 86
oseni tab 12.5-30 ..................................... 86
oseni tab 12.5-45 ..................................... 86
oseni tab 25-15mg ................................... 86
oseni tab 25-30mg ................................... 86
oseni tab 25-45mg ................................... 86
oxaliplatin inj 100mg ................................ 57
oxandrolone tab 10mg ........................... 139
oxandrolone tab 2.5mg .......................... 139
oxaprozin tab 600mg................................ 12
oxazepam cap 10mg ................................ 81
oxazepam cap 15mg ................................ 81
oxazepam cap 30mg ................................ 81
oxcarbazepin sus 300mg/5m ................... 31
oxcarbazepin tab 150mg .......................... 31
oxcarbazepin tab 300mg .......................... 31
oxcarbazepin tab 600mg .......................... 31
oxtellar xr tab 150mg................................ 31
oxtellar xr tab 300mg................................ 31
oxtellar xr tab 600mg ................................31
oxybutynin syp 5mg/5ml .........................135
oxybutynin tab 10mg er ..........................135
oxybutynin tab 15mg er ..........................135
oxybutynin tab 5mg ................................135
oxybutynin tab 5mg er ............................135
oxycod/apap tab 10-325mg ....................... 7
oxycod/apap tab 2.5-325 ........................... 7
oxycod/apap tab 5-325mg ......................... 7
oxycod/apap tab 7.5-325 ........................... 7
oxycod/asa tab .......................................... 7
oxycod/ibu tab 5-400mg ............................ 7
oxycodone cap 5mg .................................. 7
oxycodone tab 10mg ................................. 7
oxycodone tab 15mg ................................. 7
oxycodone tab 20mg ................................. 7
oxycodone tab 30mg ................................. 7
oxycodone tab 5mg ................................... 7
oxymorphone tab 10mg er ........................ 3
oxymorphone tab 15mg er ........................ 4
oxymorphone tab 20mg er ........................ 4
oxymorphone tab 30mg er ........................ 4
oxymorphone tab 40mg er ........................ 4
oxymorphone tab 5mg er .......................... 4
oxymorphone tab 7.5mg er........................ 4
oxymorphone tab hcl 10mg ....................... 7
oxymorphone tab hcl 5mg ......................... 7
oys shell ca tab /vit d ..............................176
oysco 500+d tab ....................................178
oyst shell/d tab 500mg ...........................178
oyster shell tab 500mg ...........................176
P
pacerone tab 100mg ................................96
pacerone tab 200mg ................................96
paclitaxel inj 300/50ml ..............................57
pain & fever chw 80mg .............................13
pain & fever sus 160/5ml ..........................13
pain relief dro 80/0.8ml ............................13
pain relief sus 160/5ml ............................13
pamidronate inj 30/10ml .........................155
pamidronate inj 6mg/ml ..........................155
pamidronate inj 90/10ml .........................155
panretin gel 0.1% ...................................125
paricalcitol inj 2mcg/ml ...........................155
paricalcitol inj 5mcg/ml ...........................155
paromomycin cap 250mg .........................14
paroxetin er tab 12.5mg ...........................38
paroxetin er tab 37.5mg ...........................38
paroxetine tab 10mg.................................38
paroxetine tab 20mg.................................38
paroxetine tab 25mg er ............................ 38
paroxetine tab 30mg ................................ 38
paroxetine tab 40mg ................................ 38
paser gra 4gm .......................................... 47
pataday sol 0.2% ................................... 157
patanol sol 0.1% op ............................... 157
paxil sus 10mg/5ml .................................. 38
ped elctrlyt sol fruit ................................. 172
pedvax hib inj ......................................... 152
peganone tab 250mg ............................... 31
pegasys inj ............................................... 77
pegasys inj 180mcg/m ............................. 77
pegasys inj proclick .................................. 77
pen g sod inj 5000000 .............................. 20
penicill gk/ inj dex 2mu ............................. 20
penicill gk/ inj dex 3mu ............................. 20
penicilln gk inj 5mu................................... 20
penicilln vk sol 125/5ml ............................ 20
penicilln vk sol 250/5ml ............................ 20
penicilln vk tab 250mg.............................. 20
penicilln vk tab 500mg.............................. 20
pentam 300 inj 300mg.............................. 62
pentaz/nalox tab 50-0.5mg ......................... 7
pentoxifylli tab 400mg er ........................ 109
perindopril tab 2mg .................................. 95
perindopril tab 4mg .................................. 95
perindopril tab 8mg .................................. 95
periogard sol 0.12% ............................... 120
perjeta inj 420/14ml .................................. 57
permethrin cre 5%.................................. 125
perphen/amit tab 2-10mg ......................... 66
perphen/amit tab 2-25mg ......................... 66
perphen/amit tab 4-10mg ......................... 66
perphen/amit tab 4-25mg ......................... 66
perphen/amit tab 4-50mg ......................... 66
perphenazine tab 16mg ........................... 66
perphenazine tab 2mg ............................. 66
perphenazine tab 4mg ............................. 66
perphenazine tab 8mg ............................. 66
pexeva tab 10mg ..................................... 38
pexeva tab 20mg ..................................... 38
pexeva tab 30mg ..................................... 38
pexeva tab 40mg ..................................... 38
phenelzine tab 15mg ................................ 36
phenobarb elx 20mg/5ml.......................... 24
phenobarb tab 100mg .............................. 24
phenobarb tab 15mg ................................ 24
phenobarb tab 16.2mg ............................. 24
phenobarb tab 30mg ................................ 24
phenobarb tab 32.4mg ............................. 25
phenobarb tab 60mg ................................ 25
phenobarb tab 64.8mg .............................25
phenobarb tab 97.2mg .............................25
phenylhist liq dh ...................................168
phenytoin chw 50mg ................................31
phenytoin ex cap 100mg ..........................31
phenytoin ex cap 200mg ..........................31
phenytoin ex cap 300mg ..........................31
phenytoin inj 50mg/ml ..............................32
phenytoin sus 125/5ml .............................32
phospholine sol 0.125%op .....................159
physiolyte sol..........................................156
physiosol sol irrigat .................................156
picato gel 0.015%...................................125
picato gel 0.05%.....................................125
pilocarpine tab 5mg ................................120
pilocarpine tab 7.5mg .............................120
pindolol tab 10mg ...................................104
pindolol tab 5mg .....................................105
pioglit/glim tab 30-2mg ...........................101
pioglit/glim tab 30-4mg .............................86
pioglita/met tab 15-500mg ........................86
pioglita/met tab 15-850mg ........................86
pioglitazone tab 15mg ..............................86
pioglitazone tab 30mg ..............................86
pioglitazone tab 45mg ..............................86
piper/tazoba inj 3-0.375g ..........................20
piper/tazoba inj 4-0.5gm ...........................20
pirmella tab 1/35.....................................140
piroxicam cap 10mg .................................12
piroxicam cap 20mg .................................12
plasma-lyte inj -148 ................................172
plasma-lyte inj 56/d5w ............................172
podofilox sol 0.5% ..................................125
polyeth glyc pow 3350 nf ........................131
polymyxin b/ sol trimethp ........................157
poly-vi-sol dro ........................................178
poly-vi-sol dro /iron ................................178
poly-vita dro.........................................178
pomalyst cap 1mg ....................................57
pomalyst cap 2mg ....................................57
pomalyst cap 3mg ....................................57
pomalyst cap 4mg ....................................57
pot chloride cap 10meq er ......................172
pot chloride cap 8meq er ........................172
pot chloride inj 10meq ............................172
pot chloride inj 20meq ............................172
pot chloride inj 2meq/ml .........................172
pot chloride inj 40meq ............................172
pot chloride liq 10% ................................172
pot chloride liq 20% ................................172
pot chloride tab 8meq er.........................172
pot citrate tab 1080mg ........................... 173
pot citrate tab 1620mg ........................... 173
pot citrate tab 540mg er ......................... 173
pot cl micro tab 10meq er ....................... 173
pot cl micro tab 20meq er ....................... 173
potiga tab 200mg ..................................... 24
potiga tab 300mg ..................................... 24
potiga tab 400mg ..................................... 24
potiga tab 50mg ....................................... 24
pradaxa cap 150mg ................................. 90
pradaxa cap 75mg ................................... 90
pramipexole tab 0.125mg ......................... 63
pramipexole tab 0.25mg........................... 63
pramipexole tab 0.5mg............................. 63
pramipexole tab 0.75mg........................... 63
pramipexole tab 1.5mg............................. 63
pramipexole tab 1mg................................ 63
prandimet tab 1-500mg ............................ 86
prandimet tab 2-500mg ............................ 86
prandin tab 0.5mg .................................... 87
prandin tab 1mg ....................................... 87
prandin tab 2mg ....................................... 87
pravastatin tab 10mg.............................. 113
pravastatin tab 20mg.............................. 113
pravastatin tab 40mg.............................. 113
pravastatin tab 80mg.............................. 113
prazosin hcl cap 1mg ............................... 93
prazosin hcl cap 2mg ............................... 93
prazosin hcl cap 5mg ............................... 93
pred sod pho sol 1% op ......................... 158
pred sod pho sol 5mg/5ml ...................... 138
prednicarbat cre 0.1% ............................ 125
prednicarbat oin 0.1% ............................ 125
prednisolone sol 15mg/5ml .................... 138
prednisolone sol 25mg/5ml .................... 138
prednisolone sus 1% op ......................... 158
prednisolone tab 10mg odt ..................... 139
prednisolone tab 15mg odt ..................... 139
prednisolone tab 30mg odt ..................... 139
prednisone sol 5mg/5ml ......................... 139
prednisone tab 10mg ............................. 139
prednisone tab 1mg ............................... 139
prednisone tab 2.5mg ............................ 139
prednisone tab 20mg ............................. 139
prednisone tab 50mg ............................. 139
prednisone tab 5mg ............................... 139
premarin inj 25mg .................................. 141
premarin tab 0.3mg ................................ 141
premarin tab 0.45mg .............................. 141
premarin tab 0.625mg ............................ 141
premarin tab 0.9mg ................................ 141
premarin tab 1.25mg ..............................141
premarin vag cre 0.625mg......................136
premasol sol 6%.....................................175
premphase tab .......................................141
prempro tab .625-2.5 ..............................141
prempro tab 0.3-1.5 ................................141
prempro tab 0.45-1.5 ..............................141
prempro tab 0.625-5 ...............................141
prenatal tab ........................................178
prenatal tab 27-0.8mg ........................179
prenatal vitamin tablet ............................175
prepopik pak ..........................................131
prevalite pow 4gm ..................................114
prezcobix tab 800-150 ..............................74
prezista sus 100mg/ml .............................76
prezista tab 150mg ...................................76
prezista tab 600mg ...................................76
prezista tab 75mg .....................................76
prezista tab 800mg ...................................76
priftin tab 150mg ......................................47
primaquine tab 26.3mg.............................49
primidone tab 250mg................................27
primidone tab 50mg..................................27
pristiq tab 100mg ......................................38
pristiq tab 25mg........................................38
pristiq tab 50mg........................................38
privigen inj 20grams ...............................150
proair hfa aer ..........................................163
probenecid tab 500mg..............................45
procainamide inj 100mg/ml.......................97
procalamine inj 3% .................................175
prochlorper inj 10mg/2ml ..........................66
prochlorper sup 25mg ..............................66
prochlorper tab 10mg ...............................67
prochlorper tab 5mg .................................67
procrit inj 10000/ml ...................................91
procrit inj 2000/ml .....................................91
procrit inj 20000/ml ...................................91
procrit inj 3000/ml .....................................91
procrit inj 4000/ml .....................................91
procrit inj 40000/ml ...................................91
procto-pak cre 1% ..................................125
proctozone cre -hc 2.5% ........................125
proglycem sus 50mg/ml ...........................87
prograf inj 5mg/ml ..................................149
prolastin-c inj 1000mg ............................165
proleukin inj 22mu ....................................57
prolia sol 60mg/ml ..................................155
promacta tab 12.5mg ...............................91
promacta tab 25mg ..................................92
promacta tab 50mg ..................................92
promacta tab 75mg .................................. 92
propafenone tab 150mg ........................... 97
propafenone tab 225mg ........................... 97
propafenone tab 300mg ........................... 97
propran/hctz tab 40/25 ........................... 101
propran/hctz tab 80/25 ........................... 101
propranolol cap 120mg er ...................... 105
propranolol cap 160mg er ...................... 105
propranolol cap 60mg er ........................ 105
propranolol cap 80mg er ........................ 105
propranolol inj 1mg/ml ............................ 105
propranolol sol 20mg/5ml ....................... 105
propranolol sol 40mg/5ml ....................... 105
propranolol tab 10mg ............................. 105
propranolol tab 20mg ............................. 105
propranolol tab 40mg ............................. 105
propranolol tab 60mg ............................. 105
propranolol tab 80mg ............................. 105
propylthiour tab 50mg ............................ 147
proquad inj ............................................. 152
prosol inj 20% ........................................ 175
protriptylin tab 10mg ................................ 41
protriptylin tab 5mg .................................. 41
pulmozyme sol 1mg/ml .......................... 165
purixan sus 20mg/ml ................................ 49
pyrazinamide tab 500mg .......................... 47
pyridostigm tab 60mg ............................... 46
pyridoxine inj 100mg/ml ....................... 179
Q
qc senna tab 8.6mg............................ 133
qnapril/hctz tab 10-12.5.......................... 101
qnapril/hctz tab 20-12.5.......................... 101
qnapril/hctz tab 20-25mg ........................ 101
quadracel inj .......................................... 152
qudexy xr cap 100/24hr............................ 29
qudexy xr cap 150/24hr............................ 29
qudexy xr cap 200/24hr............................ 29
qudexy xr cap 25/24hr.............................. 29
qudexy xr cap 50/24hr.............................. 29
quetiapine tab 100mg............................... 69
quetiapine tab 200mg............................... 69
quetiapine tab 25mg ................................ 69
quetiapine tab 300mg............................... 69
quetiapine tab 400mg............................... 69
quetiapine tab 50mg ................................ 69
quinapril tab 10mg ................................... 95
quinapril tab 20mg ................................... 95
quinapril tab 40mg ................................... 95
quinapril tab 5mg ..................................... 95
quinidine gl tab 324mg cr ......................... 97
quinidine su tab 200mg ............................97
quinidine su tab 300mg ............................97
quinidine su tab 300mg er ........................97
quinine sulf cap 324mg ............................62
qvar aer 40mcg ......................................161
qvar aer 80mcg ......................................161
R
rabavert inj .............................................152
raloxifene tab 60mg ................................142
ramipril cap 1.25mg ..................................96
ramipril cap 10mg .....................................96
ramipril cap 2.5mg ....................................96
ramipril cap 5mg.......................................96
ranexa tab 1000mg ................................109
ranexa tab 500mg ..................................109
ranitidine cap 150mg ..............................130
ranitidine cap 300mg ..............................130
ranitidine inj 150/6ml ..............................130
ranitidine syp 15mg/ml ...........................130
ranitidine tab 150mg ...............................130
ranitidine tab 300mg ...............................130
rapaflo cap 4mg .....................................135
rapaflo cap 8mg .....................................135
rapamune sol 1mg/ml .............................149
rebif inj 22/0.5.........................................119
rebif inj 44/0.5.........................................119
rebif titrtn sol pack ..................................119
reclast inj 5/100ml ..................................155
recombiva hb inj 10mcg/ml .....................152
recombiva hb inj 5mcg/0.5......................152
recombiva-hb inj 40mcg/ml.....................152
refresh
dro op ....................................160
refresh cell dro 1% op ............................160
refresh plus dro 0.5% op ........................160
refresh tear dro 0.5% op.........................160
regranex gel 0.01% ................................125
reguloid pow 48.57% ..........................133
relenza mis diskhale .................................77
relistor inj 12/0.6ml ......................... 129, 130
relistor inj 8/0.4ml ...................................130
relpax tab 20mg .......................................46
relpax tab 40mg .......................................46
remicade inj 100mg ................................149
renvela pak 0.8gm ..................................136
renvela pak 2.4gm ..................................136
renvela tab 800mg .................................136
repaglinide tab 0.5mg ...............................87
repaglinide tab 1mg ..................................87
repaglinide tab 2mg ..................................87
rescriptor tab 100 mg ...............................72
rescriptor tab 200mg ................................ 72
reserpine tab 0.1mg ............................... 109
restasis emu 0.05% ............................... 156
retrovir inj 10mg/ml .................................. 74
revatio inj ............................................... 164
revlimid cap 10mg .................................... 48
revlimid cap 15mg .................................... 48
revlimid cap 2.5mg ................................... 48
revlimid cap 20mg .................................... 48
revlimid cap 25mg .................................... 48
revlimid cap 5mg ...................................... 48
reyataz cap 150mg .................................. 76
reyataz cap 200mg .................................. 76
reyataz cap 300mg .................................. 76
reyataz pow 50mg .................................... 76
rheumatrex tab 2.5mg .............................. 57
ribapak pak 1000/day ............................... 77
ribapak pak 800/day ................................. 77
ribasphere cap 200mg ............................. 77
ribasphere tab 200mg .............................. 77
ribasphere tab 400mg .............................. 78
ribavirin cap 200mg .................................. 78
ribavirin tab 200mg .................................. 78
rifabutin cap 150mg ................................. 47
rifampin cap 150mg ................................. 47
rifampin cap 300mg ................................. 47
rifampin inj 600 mg ................................... 47
rifater tab.................................................. 47
riluzole tab 50mg.................................... 118
rimantadine tab 100mg ............................ 77
ringers inj ............................................... 173
ringers irr sol .......................................... 156
riomet sol ................................................. 87
risperdal inj 12.5mg .................................. 69
risperdal inj 25mg..................................... 70
risperdal inj 37.5mg .................................. 70
risperdal inj 50mg..................................... 70
risperidone sol 1mg/ml ............................. 70
risperidone tab 0.25 odt ........................... 70
risperidone tab 0.25mg ............................ 70
risperidone tab 0.5mg .............................. 70
risperidone tab 0.5mg od ......................... 70
risperidone tab 1mg ................................. 70
risperidone tab 1mg odt ........................... 70
risperidone tab 2mg ................................. 70
risperidone tab 2mg odt ........................... 70
risperidone tab 3mg ................................. 70
risperidone tab 3mg odt ........................... 70
risperidone tab 4mg ................................. 70
risperidone tab 4mg odt ........................... 70
rituxan inj 500mg...................................... 57
rivastigmine cap 1.5mg ............................33
rivastigmine cap 3mg ...............................33
rivastigmine cap 4.5mg ............................33
rivastigmine cap 6mg ...............................33
robitussin liq cgh/cold ...........................168
robitussin liq cgh/cong ..........................168
ropinirole tab 0.25mg................................63
ropinirole tab 0.5mg..................................63
ropinirole tab 1mg ....................................63
ropinirole tab 2mg ....................................63
ropinirole tab 3mg ....................................63
ropinirole tab 4mg ....................................63
ropinirole tab 5mg ....................................63
rotarix sus ..............................................153
rotateq sol ..............................................153
rozerem tab 8mg ....................................169
S
sabril pow 500mg .....................................27
sabril tab 500mg.......................................27
saizen inj 5mg ........................................142
saizen inj 8.8mg ............................. 142, 143
samsca tab 15mg ...................................170
samsca tab 30mg ...................................170
sancuso dis 3.1mg ...................................43
sandimmune cap 100mg ........................149
sandimmune cap 25mg ..........................149
sandimmune sol 100mg/ml.....................149
sandostatin kit lar 10mg .........................146
sandostatin kit lar 20mg .........................146
sandostatin kit lar 30mg .........................146
santyl oin 250/gm ...................................125
saphris sub 10mg .....................................70
saphris sub 5mg .......................................70
savella mis titr pak ..................................118
savella tab 100mg ..................................118
savella tab 12.5mg .................................119
savella tab 25mg ....................................119
savella tab 50mg ....................................119
sb bismuth tab 262mg ..........................133
sb fib lax pow 33% ...............................133
seconal cap 100mg ................................169
selegiline cap 5mg ...................................64
selegiline tab 5mg ....................................64
selenium sul lot 2.5% .............................125
selzentry tab 150mg .................................75
selzentry tab 300mg .................................75
senna
syp 8.8mg/5 ..........................133
sensipar tab 30mg ..................................145
sensipar tab 60mg ..................................145
sensipar tab 90mg ..................................145
serevent dis aer 50mcg .......................... 164
seroquel xr tab 150mg ............................. 70
seroquel xr tab 200mg ............................. 71
seroquel xr tab 300mg ............................. 71
seroquel xr tab 400mg ............................. 71
seroquel xr tab 50mg ............................... 71
sertraline con 20mg/ml ............................. 38
sertraline tab 100mg ................................ 39
sertraline tab 25mg .................................. 39
sertraline tab 50mg .................................. 39
signifor inj 0.3mg/ml ............................... 146
signifor inj 0.6mg/ml ............................... 146
signifor inj 0.9mg/ml ............................... 146
sildenafil tab 20mg ................................. 165
silver sulfa cre 1% .................................. 126
simulect inj 20mg ................................... 149
simvastatin tab 10mg ............................. 113
simvastatin tab 20mg ............................. 114
simvastatin tab 40mg ............................. 114
simvastatin tab 5mg ............................... 114
simvastatin tab 80mg ............................. 114
sirolimus tab 0.5mg ................................ 149
sirolimus tab 1mg ................................... 149
sirolimus tab 2mg ................................... 149
sirturo tab 100mg ..................................... 47
slow-mag tab...................................... 179
sm fiber pow 28.3%............................ 133
sm glucose chw raspbery ....................... 87
sm mineral oil ....................................... 134
sm vit b-1 tab 100mg............................ 179
smz/tmp ds tab 800-160........................... 22
smz-tmp inj 400-80/5................................ 22
smz-tmp sus 200-40/5.............................. 22
smz-tmp tab 400-80mg ............................ 22
sod chloride inj 0.45% ............................ 173
sod chloride inj 0.9% .............................. 173
sod chloride inj 2.5/ml ............................ 173
sod chloride inj 3% ................................. 173
sod chloride inj 5% ................................. 173
sod chloride oin 5% op ........................... 160
sod chloride sol 5% op ........................... 160
sod lactate inj 5meq/ml .......................... 173
sod poly sul sus 15gm/60 ....................... 170
sod sulfacet sol 10% op ......................... 157
sodium bicar tab 10gr............................. 133
sodium chlor sol 0.9% irr ........................ 136
sodium fluoride 2.2 mg ........................... 175
solaraze gel 3% w/w .............................. 126
soltamox sol 10mg/5ml .......................... 119
soluble fib pow therapy ......................... 134
somatuline inj 120/.5ml .......................... 146
somatuline inj 60/0.2ml...........................146
somatuline inj 90/0.3ml...........................147
somavert inj 10mg ..................................147
somavert inj 15mg ..................................147
somavert inj 20mg ..................................147
sorine tab 120mg ...................................105
sorine tab 160mg ...................................105
sorine tab 240mg ...................................105
sorine tab 80mg .....................................105
sotalol af tab 120mg ...............................105
sotalol hcl tab 160mg .............................105
sotalol hcl tab 240mg .............................105
sotalol hcl tab 80mg ...............................105
sovaldi tab 400mg ....................................78
spiriva cap handihlr ................................162
spiriva spr respimat ................................162
spirono/hctz tab 25/25 ............................101
spironolact tab 100mg ............................111
spironolact tab 25mg ..............................111
spironolact tab 50mg ..............................111
sprycel tab 100mg ....................................57
sprycel tab 140mg ....................................58
sprycel tab 20mg ......................................58
sprycel tab 50mg ......................................58
sprycel tab 70mg ......................................58
sprycel tab 80mg ......................................58
ssd cre 1% .............................................126
stavudine cap 15mg .................................74
stavudine cap 20mg .................................74
stavudine cap 30mg .................................74
stavudine cap 40mg .................................74
stavudine sol 1mg/ml..............................161
stivarga tab 40mg .....................................58
strattera cap 100mg ...............................118
strattera cap 10mg .................................118
strattera cap 18mg .................................118
strattera cap 25mg .................................118
strattera cap 40mg .................................118
strattera cap 60mg .................................118
strattera cap 80mg .................................118
streptomycin inj 1gm ................................14
stress form/ tab zinc ...............................179
stress-600/ tab zinc ...............................179
stribild tab.................................................75
suboxone mis 12-3mg ............................... 8
suboxone mis 4-1mg ................................. 8
sucralfate tab 1gm ..................................131
sudogest tab 4-60mg ..........................168
sulf/pred na sol op ..................................158
sulfacetamid sus 10% ............................126
sulfadiazine tab 500mg ............................22
sulfasalazin tab 500mg .......................... 154
sulfazine ec tab 500mg .......................... 154
sulindac tab 150mg .................................. 12
sulindac tab 200mg .................................. 12
sumatriptan inj 6mg/0.5 ............................ 46
sumatriptan tab 100mg ............................ 46
sumatriptan tab 25mg .............................. 46
sumatriptan tab 50mg .............................. 46
suprax cap 400mg ................................... 18
suprax sus 200/5ml .................................. 18
surmontil cap 100mg ................................ 41
surmontil cap 25mg .................................. 41
surmontil cap 50mg .................................. 41
sustiva cap 200mg ................................... 72
sustiva cap 50mg ..................................... 72
sustiva tab 600mg .................................... 72
sutent cap 12.5mg ................................... 58
sutent cap 25mg ...................................... 58
sutent cap 37.5mg ................................... 58
sutent cap 50mg ...................................... 58
sylatron kit 296mcg .................................. 58
sylatron kit 444mcg .................................. 58
sylatron kit 888mcg .................................. 58
symbicort aer 160-4.5 ............................ 164
symbicort aer 80-4.5 .............................. 164
symlinpen 60 inj 1000mcg ........................ 87
symlnpen 120 inj 1000mcg ...................... 87
synagis inj 50mg .................................... 150
synarel sol 2mg/ml ................................. 147
synercid inj 500mg ................................... 15
synribo inj 3.5mg ...................................... 58
synthroid tab 100mcg ............................. 144
synthroid tab 112mcg ............................. 144
synthroid tab 125mcg ............................. 144
synthroid tab 137mcg ............................. 144
synthroid tab 150mcg ............................. 144
synthroid tab 175mcg ............................. 144
synthroid tab 200mcg ............................. 144
synthroid tab 25mcg ............................... 144
synthroid tab 300mcg ............................. 145
synthroid tab 50mcg ............................... 145
synthroid tab 75mcg ............................... 145
synthroid tab 88mcg ............................... 145
syprine cap 250mg ................................... 49
systane pf sol ....................................... 160
T
tabloid tab 40mg ...................................... 49
tacrolimus cap 0.5mg ............................. 149
tacrolimus cap 1mg ................................ 149
tacrolimus cap 5mg ................................ 150
tactinal tab 325mg ................................13
tafinlar cap 50mg ......................................58
tafinlar cap 75mg ......................................58
tamiflu cap 30mg ......................................77
tamiflu cap 45mg ......................................77
tamiflu cap 75mg ......................................77
tamiflu sus 6mg/ml ...................................77
tamoxifen tab 10mg ..................................58
tamoxifen tab 20mg ..................................58
tamsulosin cap 0.4mg ............................135
tarceva tab 100mg ...................................58
tarceva tab 150mg ...................................59
tarceva tab 25mg .....................................59
targretin cap 75mg ...................................59
tarka tab 1-240 cr ...................................101
tarka tab 2-180 cr ...................................101
tarka tab 2-240 cr ...................................101
tarka tab 4-240 cr ...................................101
tasigna cap 150mg ...................................59
tasigna cap 200mg ...................................59
taxotere inj 80mg/4ml ...............................59
tazorac cre 0.05% ..................................126
tazorac cre 0.1% ....................................126
tazorac gel 0.05% ..................................126
tazorac gel 0.1% ....................................126
taztia xt cap 120mg/24 ...........................108
taztia xt cap 180mg/24 ...........................108
taztia xt cap 240mg/24 ...........................108
taztia xt cap 300mg/24 ...........................108
taztia xt cap 360mg/24 ...........................108
teflaro inj 400mg.......................................18
teflaro inj 600mg.......................................18
tegretol-xr tab 100mg ...............................32
tekamlo tab 150-10mg............................101
tekamlo tab 150-5mg..............................101
tekamlo tab 300-10mg............................102
tekamlo tab 300-5mg..............................102
tekturna hct tab 150-12.5 .......................102
tekturna hct tab 150-25mg......................102
tekturna hct tab 300-12.5 .......................102
tekturna hct tab 300-25mg......................102
tekturna tab 150mg ................................109
tekturna tab 300mg ................................109
telmis/amlod tab 40-10mg ......................102
telmis/amlod tab 40-5mg ........................102
telmis/amlod tab 80-10mg ......................102
telmis/amlod tab 80-5mg ........................102
telmisartan tab 20mg ................................94
telmisartan tab 40mg ................................94
telmisartan tab 80mg ................................94
temazepam cap 15mg ............................169
temazepam cap 22.5mg ......................... 169
temazepam cap 30mg............................ 169
temazepam cap 7.5mg........................... 169
tenivac inj 5-2lf ....................................... 180
terazosin cap 10mg .................................. 93
terazosin cap 1mg .................................... 93
terazosin cap 2mg .................................... 93
terazosin cap 5mg .................................... 93
terbutaline inj 1mg/ml ............................. 164
terconazole cre 0.4% ............................. 136
terconazole sup 80mg ............................ 136
testost cyp inj 200mg/ml......................... 140
testost enan inj 200mg/ml ...................... 140
testred cap 10mg ................................... 140
tet/dip tox inj 2-2 lf .................................. 153
tetanus tox inj 5lf ads ............................. 153
teveten hct tab 600-12.5 ........................ 102
teveten hct tab 600-25mg ...................... 102
thalomid cap 100mg ................................. 49
thalomid cap 150mg ................................. 49
thalomid cap 200mg ................................. 49
thalomid cap 50mg ................................... 49
theophylline tab 100mg cr ...................... 162
theophylline tab 200mg cr ...................... 162
theophylline tab 300mg er ...................... 162
theophylline tab 450mg er ...................... 162
theophylline tab 600mg er ...................... 162
thera beta- tab carotene ........................ 179
thiamine hcl inj 100mg/ml ....................... 179
thioridazine tab 100mg ............................. 67
thioridazine tab 10mg ............................... 67
thioridazine tab 25mg ............................... 67
thioridazine tab 50mg ............................... 67
thiothixene cap 10mg ............................... 67
thiothixene cap 1mg ................................. 67
thiothixene cap 2mg ................................. 67
thiothixene cap 5mg ................................. 67
thymoglobuln inj 25mg ........................... 151
tiagabine tab 2mg .................................... 27
tiagabine tab 4mg .................................... 27
ticlopidine tab 250mg ............................... 92
tikosyn cap 125mcg ................................. 97
tikosyn cap 250mcg ................................. 97
tikosyn cap 500mcg ................................. 97
timolol gel sol 0.25% op ......................... 159
timolol gel sol 0.5% op ........................... 159
timolol mal sol 0.25% op ........................ 159
timolol mal sol 0.5% op .......................... 159
timolol mal tab 10mg .............................. 105
timolol mal tab 20mg .............................. 106
timolol mal tab 5mg ................................ 106
tivicay tab 50mg .......................................75
tizanidine tab 2mg ..................................169
tizanidine tab 4mg ..................................169
tobra/dexame sus 0.3-0.1%....................158
tobramycin inj 10mg/ml ............................14
tobramycin inj 80mg/2ml ..........................14
tobramycin neb 300/5ml ...........................14
tobramycin sol 0.3% op ..........................157
tolazamide tab 250mg ..............................87
tolazamide tab 500mg ..............................87
tolbutamide tab 500mg .............................87
tolmetin sod cap 400mg ...........................12
tolmetin sod tab 600mg ............................12
tolnaftate cre 1% ..................................127
tolnaftate pow 1% .................................127
tolnaftate sol 1%...................................127
tolterodine tab 1mg ................................135
tolterodine tab 2mg ................................135
topiramate cap 15mg................................29
topiramate cap 25mg................................29
topiramate cap er 100mg .........................29
topiramate cap er 150mg .........................29
topiramate cap er 200mg .........................29
topiramate cap er 25mg ...........................29
topiramate cap er 50mg ...........................29
topiramate tab 100mg ..............................46
topiramate tab 200mg ..............................29
topiramate tab 25mg ................................29
topiramate tab 50mg ................................29
toposar inj 1gm/50ml ................................59
topotecan inj 4mg .....................................59
torisel sol 25mg/ml ...................................59
torsemide tab 100mg..............................110
torsemide tab 10mg................................110
torsemide tab 20mg................................110
torsemide tab 5mg .................................110
total b/c tab..........................................179
tpn electrol inj .........................................173
tracleer tab 125mg .................................165
tracleer tab 62.5mg ................................165
tramadl/apap tab 37.5-325 ........................ 7
tramadol hcl tab 50mg ............................... 7
trando/verap tab 1-240 cr .......................102
trando/verap tab 2-180 cr .......................102
trando/verap tab 2-240 cr .......................102
trando/verap tab 4-240 cr .......................102
trandolapril tab 1mg..................................96
trandolapril tab 2mg..................................96
trandolapril tab 4mg..................................96
tranex acid inj 100mg/ml ..........................92
tranex acid tab 650mg ..............................92
transderm-sc dis 1.5mg............................ 42
tranylcyprom tab 10mg............................. 36
travasol inj 10%...................................... 175
travatan z dro 0.004% ............................ 156
trazodone tab 100mg ............................... 35
trazodone tab 150mg ............................... 35
trazodone tab 300mg ............................... 35
trazodone tab 50mg ................................. 35
treanda inj 100mg .................................... 59
treanda inj 45/0.5ml ................................. 59
trecator tab 250mg ................................... 47
trelstar dep inj 3.75mg.............................. 59
trelstar la inj 11.25mg ............................... 59
trelstar mix inj 22.5mg .............................. 59
tretinoin cap 10mg ................................... 59
trexall tab 10mg ..................................... 150
trexall tab 15mg ..................................... 150
trexall tab 5mg ....................................... 150
trexall tab 7.5mg .................................... 150
triamcin ace inj 10mg/ml ........................ 139
triamcin ace inj 40mg/ml ........................ 139
triamcin/ora pst 0.1% ............................. 120
triamcinolon cre 0.025%......................... 126
triamcinolon cre 0.1%............................. 126
triamcinolon cre 0.5%............................. 126
triamcinolon lot 0.025% .......................... 126
triamcinolon lot 0.1% .............................. 126
triamcinolon oin 0.025% ......................... 126
triamcinolon oin 0.1% ............................. 126
triamcinolon oin 0.5% ............................. 126
triamt/hctz cap 50-25mg ......................... 103
triamt/hctz tab 37.5-25 ........................... 103
triamt/hctz tab 75-50mg ......................... 103
triazolam tab 0.125mg............................ 169
triazolam tab 0.25mg.............................. 169
tribenzor20- tab 5-12.5mg ...................... 103
tribenzor40- tab 10-12.5 ......................... 103
tribenzor40- tab 10-25mg ....................... 103
tribenzor40- tab 5-12.5mg ...................... 103
tribenzor40- tab 5-25mg ......................... 103
tri-buff asa tab 325mg .............................. 13
triderm cre 0.1%..................................... 126
trifluoperaz tab 10mg ............................... 67
trifluoperaz tab 1mg ................................. 67
trifluoperaz tab 2mg ................................. 67
trifluoperaz tab 5mg ................................. 67
trifluridine sol 1% op ............................... 157
trihexyphen elx 0.4mg/ml ......................... 62
trihexyphen tab 2mg ................................ 62
trihexyphen tab 5mg ................................ 62
trimethoprim tab 100mg ........................... 15
trinessa tab ............................................140
tri-previfem tab .......................................140
trisenox sol 10mg/10m .............................59
tri-sprintec tab ........................................140
triumeq tab ...............................................74
tri-vi-sol dro /iron ..................................179
tri-vi-sol sol ...........................................179
tri-vita sol............................................179
trokendi xr cap 100mg ..............................30
trokendi xr cap 200mg ..............................30
trokendi xr cap 25mg ................................30
trokendi xr cap 50mg ................................30
trumenba inj ...........................................153
truvada tab 200-300 .................................74
tussin cf liq ..........................................168
tussin dm liq max ................................168
twinrix inj ................................................153
tybost tab 150mg ......................................75
tygacil inj 50mg ........................................15
tykerb tab 250mg .....................................59
typhim vi inj ............................................153
tysabri inj 300/15ml ................................119
tyzeka tab 600mg .....................................78
tyzine ped dro 0.05%..............................164
U
uceris tab 9mg........................................139
u-cort cre 1% ..........................................126
uloric tab 40mg.........................................45
uloric tab 80mg.........................................45
unithroid tab 100mcg ..............................145
unithroid tab 112mcg ..............................145
unithroid tab 125mcg ..............................145
unithroid tab 150mcg ..............................145
unithroid tab 175mcg ..............................145
unithroid tab 200mcg ..............................145
unithroid tab 25mcg ................................145
unithroid tab 300mcg ..............................145
unithroid tab 50mcg ................................145
unithroid tab 75mcg ................................145
unithroid tab 88mcg ................................145
ursodiol tab 250mg .................................130
ursodiol tab 500mg .................................130
uvadex inj 20mcg/ml.................................59
V
valacyclovir tab 1gm .................................78
valacyclovir tab 500mg .............................78
valchlor gel 0.016% ................................126
valcyte sol 50mg/ml ..................................72
valganciclov tab 450mg ............................72
valproate inj 500/5ml ................................ 27
valproic acd cap 250mg ........................... 27
valproic acd syp 250/5ml.......................... 27
valsart/hctz tab 160-12.5 .......................... 87
valsart/hctz tab 160-25mg ...................... 103
valsart/hctz tab 320-12.5 ........................ 103
valsart/hctz tab 320-25mg ...................... 103
valsart/hctz tab 80-12.5 .......................... 103
vancomycin cap 125mg ........................... 15
vancomycin cap 250mg ........................... 15
vancomycin inj 1000mg............................ 16
vancomycin inj 10gm................................ 16
vancomycin inj 500mg.............................. 16
vandazole gel 0.75% .............................. 137
vaqta inj 25/0.5ml ................................... 153
vaqta inj 50unt/ml ................................... 153
varivax inj ............................................... 153
vectibix inj 100mg .................................... 60
velcade inj 3.5mg ..................................... 60
venlafaxine cap 150mg er ........................ 39
venlafaxine cap 37.5 er ............................ 39
venlafaxine cap 75mg er .......................... 39
venlafaxine tab 100mg ............................. 39
venlafaxine tab 150mg er ......................... 39
venlafaxine tab 225mg er ......................... 39
venlafaxine tab 25mg ............................... 39
venlafaxine tab 37.5 er ............................. 39
venlafaxine tab 37.5mg ............................ 39
venlafaxine tab 50mg ............................... 39
venlafaxine tab 75mg ............................... 39
venlafaxine tab 75mg er ........................... 39
ventavis sol 10mcg/ml ............................ 165
ventavis sol 20mcg/ml ............................ 165
ventolin hfa aer ...................................... 164
verapamil cap 100mg er......................... 108
verapamil cap 120mg er......................... 108
verapamil cap 180mg er......................... 108
verapamil cap 200mg er......................... 108
verapamil cap 240mg er......................... 108
verapamil cap 300mg er......................... 108
verapamil cap 360mg sr ......................... 108
verapamil inj 2.5mg/ml ........................... 108
verapamil tab 120mg.............................. 108
verapamil tab 120mg er ......................... 108
verapamil tab 180mg er ......................... 108
verapamil tab 240mg er ......................... 109
verapamil tab 40mg ............................... 109
verapamil tab 80mg ............................... 109
versacloz sus 50mg/ml............................. 71
vesicare tab 10mg .................................. 135
vesicare tab 5mg.................................... 135
victrelis cap 200mg ..................................78
videx sol 2gm ...........................................74
vigamox dro 0.5% ..................................157
viibryd kit ..................................................35
viibryd tab 10mg .......................................35
viibryd tab 20mg .......................................35
viibryd tab 40mg .......................................35
vimpat inj 200mg/20 .................................32
vimpat sol 10mg/ml ..................................32
vimpat tab 100mg .....................................32
vimpat tab 150mg .....................................32
vimpat tab 200mg .....................................32
vimpat tab 50mg.......................................32
vinblastine inj 1mg/ml ...............................60
vincasar pfs inj 1mg/ml .............................60
vincristine inj 1mg/ml ................................60
vinorelbine inj 10mg/ml.............................60
viracept tab 250mg ...................................76
viracept tab 625mg ...................................76
viramune xr tab 100mg.............................73
virazole inh 6gm .......................................77
viread pow 40mg/gm ................................74
viread tab 150mg .....................................74
viread tab 200mg .....................................74
viread tab 250mg .....................................74
viread tab 300mg .....................................74
vitamin a cap 10000unt .......................179
vitamin b-1 tab 100mg ...........................179
vitamin b-1 tab 50mg .............................179
vitamin b-6 tab 100mg ...........................179
vitamin b-6 tab 50mg .............................179
vitamin c chw 250mg ...........................179
vitamin c chw 500mg ...........................179
vitamin c tab 250mg ............................180
vitamin c tab 500mg ............................180
vitamin k1 inj 10mg/ml ..........................180
vitekta tab 150mg .....................................75
vitekta tab 85mg .......................................75
voltaren gel 1% ......................................126
voriconazole inj 200mg.............................45
voriconazole sus 40mg/ml ........................45
voriconazole tab 200mg ...........................45
votrient tab 200mg ...................................60
vyfemla tab 0.4-35 ..................................140
vytorin tab 10-10mg................................111
vytorin tab 10-20mg................................112
vytorin tab 10-40mg................................112
vytorin tab 10-80mg................................112
W
warfarin tab 10mg ....................................90
warfarin tab 1mg ...................................... 90
warfarin tab 2.5mg ................................... 90
warfarin tab 2mg ...................................... 90
warfarin tab 3mg ...................................... 90
warfarin tab 4mg ...................................... 90
warfarin tab 5mg ...................................... 90
warfarin tab 6mg ...................................... 90
warfarin tab 7.5mg ................................... 90
welchol pak 3.75gm ............................... 114
welchol tab 625mg ................................. 114
X
xalkori cap 200mg .................................... 60
xalkori cap 250mg .................................... 60
xarelto star tab 15/20mg .......................... 90
xarelto tab 10mg ...................................... 90
xarelto tab 15mg ...................................... 91
xarelto tab 20mg ...................................... 91
xenazine tab 12.5mg .............................. 118
xenazine tab 25mg ................................. 118
xgeva inj................................................. 155
xifaxan tab 550mg .................................... 16
xolair sol 150mg ..................................... 165
xtandi cap 40mg....................................... 60
xyrem sol 500mg/ml ............................... 170
Y
yervoy inj 50mg ........................................ 60
yf-vax inj................................................. 153
Z
zafirlukast tab 10mg ............................... 162
zafirlukast tab 20mg ............................... 162
zaleplon cap 10mg ................................. 170
zaleplon cap 5mg ................................... 170
zaltrap inj 100/4ml .................................... 60
zanosar inj 1gm........................................ 60
zavesca cap 100mg ............................... 128
zazole cre 0.4% ..................................... 137
zazole cre 0.8% ..................................... 137
zelboraf tab 240mg .................................. 60
zemplar cap 1mcg .................................. 155
zemplar cap 2mcg .................................. 155
zenpep cap 10000unt............................. 128
zenpep cap 15000unt............................. 128
zenpep cap 20000unt............................. 128
zenpep cap 25000unt .............................128
zenpep cap 3000unit ..............................129
zenpep cap 5000unit ..............................129
zetia tab 10mg........................................114
ziagen sol 20mg/ml ..................................74
zidovudine cap 100mg .............................74
zidovudine syp 50mg/5ml .........................74
zidovudine tab 300mg ..............................74
zinc oxide oin 20% ...............................127
zinecard inj 250mg ...................................60
ziprasidone cap 20mg ..............................71
ziprasidone cap 40mg ..............................71
ziprasidone cap 60mg ..............................71
ziprasidone cap 80mg ..............................71
zirgan gel 0.15% ....................................157
zohydro er cap 10mg................................. 4
zohydro er cap 15mg................................. 4
zohydro er cap 20mg................................. 4
zohydro er cap 30mg................................. 4
zohydro er cap 40mg................................. 4
zohydro er cap 50mg................................. 4
zoledronic inj 4mg/5ml............................155
zolinza cap 100mg ...................................60
zolpidem tab 10mg .................................170
zolpidem tab 5mg ...................................170
zometa inj 4mg/100 ................................155
zonisamide cap 100mg ............................26
zonisamide cap 25mg ..............................26
zonisamide cap 50mg ..............................26
zortress tab 0.25mg................................150
zortress tab 0.5mg .................................150
zortress tab 0.75mg................................150
zostavax inj ............................................153
zubsolv sub 1.4-0.36 ................................. 9
zubsolv sub 5.7-1.4 ................................... 9
zubsolv sub 8.6-2.1 ................................... 9
zydelig tab 100mg ....................................60
zydelig tab 150mg ....................................60
zyflo cr tab 600mg ..................................162
zyflo tab 600mg ......................................162
zykadia cap 150mg ..................................60
zyprexa relp inj 210mg ...........................180
zytiga tab 250mg ......................................61
zyvox sus 100mg/5m................................16
zyvox tab 600mg ......................................16